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�.. <br /> -4G <br /> SAN JOAQUIN COUNTY D + F <br /> ?, t: ENVIRONMENTAL HEALTH DEPARTMENT D Return this form by <br /> 600.East,Main Street, Stockton,CA 95202-2708nth <br /> P Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.Sigov.org/e�CC <br /> ''�}}N 4 4 ZQj� <br /> SEPTAGE CLEANER'S REPORT ENVIRONMNT HEALTH <br /> Company Name: �. J j QERMIT,�ERVICE <br /> Repa -t for the onth of ye d <br /> CV6 # w <br /> Company Address: r Signature. <br /> [reef Address p city Zip Code <br /> All information submitted must be com fete, accurate, and legible <br /> i <br /> r <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAL NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED (G) GREASE TRAP FACILITY <br /> PLEASE�INCLUDE STREET #, DIRECTION, STREET NAME AND CITY (C) CHEMICAL <br /> ci <br /> 3 / <br /> City <br /> city '-� /� <br /> may' .r cit <br /> 'Cit <br /> f � i <br /> City <br /> city <br /> pit <br /> Cit l/ SO <br /> r= "D/ <br /> city <br /> City <br /> -7 Cit <br /> Cit <br /> cit r' sdl. � /moi ✓/1�� <br /> �d cit ' <br /> r � ' <br /> u i{J ,t/ , / �� jd"e.'Z✓ cit <br /> Cit f--- �� ' <br /> l <br /> cite 1rr �C/ //L <br /> E3iD 42-04 } � <br /> - Septic/Cesspool Report <br /> 'a. <br />