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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL,HEALTH DEPARTMENT Return this form by <br /> # 600 East Main Street, Stockton,CA 95202-2708 <br /> the 12th of each month <br /> p Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov'.org/ehd <br /> Gr�ORCt � i <br /> SEPTAGE CLEANER'S REPORT , <br /> Company Name. <br /> Report for Zth� onth of: ye.0 <br /> Company Address: Signature•Street Address City Zip Code <br /> All information submitted must he com tete, accurate, and legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDVNTIAL NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER t PUMPED (G) GREASE TRAP FACILITY <br /> PLEASE INCLUDE STREET k, DIRECTION, STREET NAME AND CITY a (C) CHEMICAL <br /> O t City <br /> City <br /> d', �Cit i <br /> 20 <br /> d <br /> z 764V <br /> CityCity <br /> �- <br /> -Z <br /> city <br /> Cit / l <br /> ' cit {{{rrr <br /> city <br /> city <br /> City <br /> Cit Ia <br /> 1 <br /> City <br /> 7yy <br /> r1 ` <br /> x <br /> Cityy <br /> Cit <br /> Ci , <br /> ' Cit <br /> EEO 42-U4 <br /> x � t <br /> } Septic/Cesspool Report <br /> .:7 ii <br />