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SAN JOAQUIN COUNTY <br /> HIE <br /> CIEVED <br /> ENVIRONMENTAL FfEALTH DEPARTMENT Return this form by <br /> ` 600 East Main Street, Stockton, CA 95202-2708the 12'h of each month <br /> Ulu Telephone:(209)468-3420 Fax:(209)464-0I38 Web:www.Sjgov.org/ d N T,.E <br /> C•. 4 J q <br /> 4CrFO.Rei , <br /> ENVI NPENT HEA4T SEPTAGE CLEANER'S REPORT <br /> Company Name: ACle Report for th onth o . <br /> Company Address: Signatlii`� <br /> Street Address city Zip Cade <br /> All inf6rmation submitted must be complete, accurate, and legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONEGALLONS (R) RESIDENTIAL NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER "PUMPED (G) GREASE TRAP <br /> PLEASE INCLUDE STREET 01, DIRECTION, STREET NAME AND <br /> CITY (C) CHEMICAL FACILITY <br /> 3 f b r /�,/ { �� 1,1777/✓ <br /> City <br /> City , <br /> f. <br /> I S / o;. J j CityIe <br /> Cit <br /> Cit i� I <br /> . <br /> City --� <br /> #. <br /> �l/ <br /> t <br /> �O r O. ,L,��J aGT(i / / C Cit <br /> F-10 <br /> cizy <br /> Cit <br /> 14� Cit <br /> . �� 'oe <br /> ciy <br /> City <br /> city 0-6 ze- <br /> ZZ a City <br /> _ . <br /> 0 City <br /> City <br /> d �i r r, <br /> Cit V ,Aor <br /> , <br /> t K <br /> EHD 42-04 '4 �' <br /> — s Septic/Cesspool Report <br /> n <br />