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SAN JOAQUIN COUNTY <br /> { ! ENVIRONMENTAL HEALTH DEPARTMENT Return this form by <br /> 600 East Main Street, Stockton,CA 95202-2708 the 12th of each month <br /> �q�lFo �`P • T4plione:(209)468-3420 Fax:(209)464-0138 Web:www.sigov.org/ehd <br /> i • SEPTAGE CLEAN R'S REPORT <br /> Company Name: <br /> + <br /> Company Address: Report for the ronth o . ear&J <br /> Street Address Signature: <br /> City Zip Code <br /> All information submitted must be com fete, acurate, and legible <br /> DATE NAME OF BUSINESS OR <br /> PUMPED i ADDRESS WHERE WORK WAS DONE GALLONS �) RESIDENTIAL NAME OF TREATMENT <br /> PROPERTY OWNER I PUMPED (C) <br /> GREASE TRAP <br /> PLEASE IN;CLUDE STREET 4, DIRECTION, STREET NAME AND CITY C) CHEMICAL FACILFTY <br /> city e-747T�4z 4 A- 10 <br /> City z"'' <br /> Citz <br /> l <br /> city <br /> CityG! /� <br /> C3 <br /> Clt <br /> City <br /> Cit <br /> Cit I <br /> - Ci <br /> ty <br /> City <br /> Ci <br /> Cit <br /> City <br /> Ci[ <br /> Cit <br /> City <br /> Cit <br /> EHD 42-04 <br /> Septic/Cesspool Report <br />