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caa SAN JOAQUIN COUNTY <br /> j ENVIRONMENTAL HEALTH DEPARTMENT Return this form by <br /> 600 East Main Street, Stockton,CA 95202-2708 the th of each month <br /> •'� .A Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sigov.org/ehd <br /> �crFo,za. <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: Report for the m, th of. year6LJ� <br /> Company Address: �S Signature: <br /> Street Address City Zip Code <br /> All information submitted must be complete, accurate, and legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAL NAME OF TREATMENT l <br /> PUMPED PROPERTY OWNER PUMPED (G) GREASE TRAP FACILITY <br /> PLEASE INCLUDE STREET tl, DIRECTION, STREET NAME AAND CITY C) CHEMICAL <br /> City <br /> d <br /> City �� G <br /> ca <br /> /y p� Cit <br /> Cit <br /> Cit <br /> Ci <br /> City <br /> Ci <br /> Citv <br /> Cit <br /> City <br /> Cit <br /> City <br /> Cit <br /> Cit <br /> Ci <br /> Cit <br /> EIiD 42-04 <br /> "'' Septic/Cesspool Report <br />