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SAN JOAQUIN COUNTY RECEIVED <br /> d <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> .� 600 East Main Street, Stockton, CA 95202-3029 Jill 1 N 2012 12d' of each month <br /> Telephone:(209) 468-3420 Fax:(209) 464-0138 Web:www.sjgov.arg/ehd <br /> F' SEPTAGE CLEANER'S REPORT ENVpIIRONMENTALHEALIY <br /> Company Name: Repo rto�N} �es f: year <br /> Company Address: Dt 7 � Signature: <br /> St ddre s CM Tip Code <br /> All information submitted must be complete, accurate, and legible (R) RESmENTU1l <br /> W GALLONS NAME OF TREATMENT <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE (G) DREASE I <br /> PUMPED PROPERTY OWNER PUMPED FACILITY <br /> // PLEASE INCLUDE STREET e, DIRECTION, STREET NAME AND CITY G CNF1110AL <br /> a 1 <br /> } C. <br /> O <br /> ~ G' <br /> C" <br /> C <br /> city <br /> city <br /> city <br /> C <br /> 0 <br /> City <br /> o <br /> 0 <br /> ( C z <br /> a g <br /> C r <br /> 0 <br /> cityo <br /> Cayr <br /> 0 <br /> FF C' cr <br /> C o <br /> I <br /> c. <br /> j C. <br /> �I E <br /> CRY <br /> ru I <br /> SEPTAGE CLEANERS REPORT <br /> m EHD 42-04 <br /> + 1014107 <br /> ' i <br />