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- -- - �s SAN JOAQU[N COUNTY <br /> ' f ENVIRONMENTAL HEALTH DEPARTMENT Return this form by <br /> 600 East Main Street, Stockton,CA 95202-2708 #, the 12th of each month <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> °4�tfio�a`¢ f SEPTAGE CL ANER'S REPORT <br /> Company Name: Report for the nth of: yeaf.YXJ[� <br /> Company Address: <br /> p y l Signature• <br /> Street Address City Zip Code <br /> All inrormation submitted must be com lete, accurate, and legible e <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAL NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PLEASEIINCLIIDE STREET k, DIRECTION, STREET NAME AND CITY `. PUMPED (G) GREASETRAP FACILITY <br /> 4 (C) CHEMICAL <br /> CityA <br /> City <br /> City <br /> 4 <br /> City <br /> City <br /> city <br /> { City <br /> City <br /> Cit <br /> § Cit <br /> 01+ city <br /> 1. <br /> city <br /> City <br /> E <br /> Cit <br /> Cit <br /> J <br /> Cityt <br /> r <br /> Citv <br /> E i <br /> city <br /> 4 <br /> EHD 42-04 <br /> _ ____ �S Septic/Cesspool Report <br /> ll <br />