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SAN JOAQUIN COUNTY 'a s <br /> z ENVIRONMENTAL HEALTH DEPARTMENT Return This form by <br /> K APp <br /> t , Cvw9 600 East Main Street Stockton,CA 95202-2708 the 12th of each month_ <br /> y. CCppI��f rr� �! 4 h��T 1 1� Telephone:(209)468-3420 Fa11' x:(209)464-0138 Web:www.sjgo or <br /> • c4�IF6RT'kc LiYV� Ul1 'i €YI !'��ALTN � , <br /> _ pZNP' E lr SEPTAGE CLEANER'S REPORT } <br /> Company Name: i ' <br /> C Report for the month of: .0-aV .1yeatr <br /> lCompany Address: � SigjiatureQ//.`Y,�,v�,� : � <br /> Sweet Address City Zip Coe Tl-7 ::{ <br /> i A!1 information submitted must be complete accurate, and legible <br /> DATE NAME OF BUSINESS ORADDRESS WHERE WORK WAS DONE GALLONS ONS (R) RESIDENTIAL NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER [i' "'i- PUMPED (G) GREASE TRAP FACILITY <br /> PLEASE INCLUDE STREET #, DIRECTION,,. STREET NAME AND CIT\ (C) CHEMICAL <br /> Ci DQ C <br /> a w .5 � <br /> c� r , c, . ( <br /> r Uy� c <br /> cityc <br /> a:s�9, err/ / 71!� � � city� ,•�N �— OG}� !' L�� <br /> I— City <br /> t e.o 23 •, Z E Cityr6Q.a <br /> 0 9 } LY-2 5 Cit . aF` ,,D 6a / t <br /> `! + d ) I 1'G i j. �f 1 0 22 Cit 1 U' — �. <br /> .6 Avcq -1<56 cit :'41041 <br /> A o' 6 Ci <br /> Icz � 0p!• d <br /> t� �� Yom' ��, i i �c i� <br /> cit717 <br /> Ci C. <br /> i <br /> J-26- 1t ol, cit oco 6 <br /> r city 7 , <br /> City . G <br /> HHD 42-04 1,. Septic/Cesspool Report <br /> w ���:��..1 � �- __ _� ....•-�...�� ....-«�.L. �� - - - ..: - _ fix- � _.� -1 � � :...�� - : <br />