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SAN JOAQUIN COUNTY <br /> ?, ENVIRONMENTAL HEALTH DEPARTMENT F eturn this form by <br /> ` 600 East Main Street, Stockton,CA 95202-2708 [ ���� the I2`h of each month <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sigov.orwehd - ' <br /> �R(fFOR�`pDEC 0 3 2009 <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: LRep rt fomw g y�`ear <br /> • <br /> Company Address: Signature, <br /> Street Address City Zig Code - "- <br /> t6 } <br /> All information submitted must be complete, accurate, and legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORT{WAS DONE GALLONS (R) RESIDENTIAL NAME OF TREATMENT t <br /> PUMPED PROPERTY OWNER PUMPED (G) GREASE TRAP FACILITY <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY', C CHEMICAL <br /> ITA 'a T ci .Z. O <br /> s`. ci �ik 11. j <br /> ( 0Cit . ' S ST/L <br /> 1,1144e <br /> ry Ci , <br /> & Pf -1-S D Rnmznntcity / <br /> i. <br /> 10 cityC <br /> CL=Yl'�C7 i1tP7+ <br /> Ct <br /> r ODO . r <br /> qba"s-_5 911CCColo,F2 �Q Ci P <br /> ' <br /> ! Ccit , , I <br /> 17 <br /> � Qo Cit <br /> 41—s- ►t Ci <br /> tt- 0 `C 400 �- <br /> -2 -o5r h <br /> C. city i 1 <br /> o-0 <br /> City <br /> ~Cit <br /> j <br /> f Cit <br /> �t Cit <br /> EHD 42-04 <br /> . Septic/Cesspool-Report <br /> — ___. -- <br />