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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by <br /> ` 600 East Main Street, Stockton,CA 95202-2708 ch <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sigov.org/ehd the 12 of each month <br /> e �Q � <br /> 4<rFarect <br /> SEPTAGE CLEANER'S REPORT } <br /> Company Name: l Report#for the nth of: yeap� <br /> Company Address: �O #' — - <br /> Signature• . <br /> Street Address City tp Code <br /> r <br /> All information submitted must be complete, ac urate, and legible <br /> DATE NAMF OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAJA <br /> E OF TREATMENT <br /> PUMPED PROPERTY OWNER 'f PUMPED (G) GREASE TRAFACILITY <br /> PLEASE IN LUDE STREET ti, DIRECTION, STREET NAME AND CITY g, C) CHEMICAL <br /> II <br /> w. .. t City <br /> Cit a <br /> City ` <br /> Ci!Y <br /> city : <br /> city1" <br /> - � Cit . <br /> cityI <br /> Cit <br /> city <br /> ci <br /> 4. <br /> 15 <br /> city <br /> City <br /> � I <br /> Cit <br /> City <br /> cit , <br /> City <br /> Cit r <br /> I <br /> EIID 42-44 Septic/Cesspool Report <br /> Y <br />