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��• Y' o0 SAN JOAQUIN COUNTY <br /> 2 y, ENVIRONMENTAL HEALTH DEPARTMENT Return this form by <br /> ` 600 East Main Street, Stockton,CA 95202-2708 the 12th of each month <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web.www.sjgov.org/chd <br /> �QL1F('jR��P <br /> SEPTAGE CLEANER'S REPORT J� <br /> Company Name: <br /> > Report for the month of: -year/,,, /e-,/—,S <br /> 9� <br /> Company Address: ! � w a Signature: <br /> Street Address city Zip Code <br /> All information submitted must be com tete, accurate, and legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE' GALLONS (R) RESIDENTIAL NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED (G) GREASE TRAP FACILITY <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY (Cl CHEMICAL <br /> Gi <br /> Cit <br /> d7 <br /> City �i <br /> city <br /> City <br /> / ci <br /> Cit <br /> Cit <br /> City <br /> City <br /> City <br /> cit <br /> A <br /> Cit <br /> city <br /> city <br /> Cit <br /> CII <br /> Cit <br /> Cit <br /> city <br /> FHD 42-04 <br /> , Septic/Cesspool Report <br />