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SAN JOAQUIN COUNTY <br /> 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 Fur:(209)464-0138 Web;www.sjgov.org/chd <br /> �rPaRa <br /> SEPTAGE CLEANER'S REPORT <br /> Company Nam . Report for the nth of: year <br /> Company Address: a QJ a Signature: <br /> 7—Address city Zip Code <br /> All information submitted must be com lete, accurate, and legible <br /> DATE NAME OF BUSP.NESS 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 /> city zoo 6) <br /> Ci Z;S/ >d f� <br /> C, o <br /> City � [5 ✓L <br /> city <br /> I 3 Ci -fid C,(G_S <br /> Cit <br /> Ci <br /> c; <br /> cit <br /> Ci <br /> Ci <br /> Gi <br /> Cit <br /> Cit <br /> Cit <br /> Ci <br /> Ci <br /> Cit <br /> EHD 42-04 <br /> Septic/Cesspool Report <br />