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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT ffthe <br /> n this form b <br /> K 600 East Main Street, Stockton,CA 95202-2708 `"ofeach month <br /> r r Telephone.(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> QI t FORA` <br /> S PTAGE CLE ER'S REPORT <br /> % t <br /> Company Name: M , / <br /> / Report for the nth of: yea <br /> Company Address: <br /> v"t Address Signature- <br /> city City 7ip Code <br /> All information submitted must be cum fete, accurate, and legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK NAS DON (RI REsmenruL <br /> PUMPED PROPERTY OWNER GALLONS NAME OF TREATMENT <br /> PLEASE INCLUDE STREET p, DIRECTION. STREET NAME AND CITY PUMPED (t') 4REASETRAP FACILITY <br /> j� <br /> (c) CHEMICAL <br /> C C�- ,,.J <br /> Cie a <br /> C1 <br /> City, <br /> LTJtkenn z Lla City, I <br /> I Ham._, ..✓ (� city <br /> u ,-T Asa o If <br /> J4/ ' City lT <br /> City <br /> ' v Ci <br /> Cit <br /> C1 <br /> Ci <br /> Ci <br /> Ci <br /> C' <br /> O <br /> EHD 42-04 <br /> Septic/Cesspool Repan <br />