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SAN JOAQUIN COUNTY RECEIVE® <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> tt 600 East Main Street, Stockton, CA 95202-3029 MAY 10 2012 12N'of each month <br /> •� Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sigov.org/ehd <br /> a <br /> SEPTAGE CLEANER'S REPORT ENVIRONMENTAL HEALTH <br /> Company Name: (/ RepoA%V& && %f:- year <br /> Company Address: Signature: " <br /> SDeeIA mss City ZAP Code <br /> All information submitted must be complete, accurate, and legible <br /> m DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIu NAME OF TREATMENT <br /> G) GREASE TRAP <br /> PUMPED PROPERTY OWNER PUMPED ( FACILITY <br /> Q ` PLEASE INCL UDF STREET t, DIRECTION, STREET NAME AND CITY C CHEMICAL <br /> CHEMICAL <br /> city <br /> 0 <br /> �i <br /> city <br /> chy <br /> city <br /> city <br /> CKY <br /> city <br /> CRY <br /> t C <br /> CRY <br /> city <br /> CRYE <br /> 0 <br /> LL CRY <br /> LLCE city <br /> Chy <br /> IS) <br /> N cvY <br /> ED <br /> Ou <br /> N <br /> EHD 12-04 SEPTAGE CLEARERS REPORT <br /> m tixam <br /> rCIE <br /> F <br />