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f <br /> moo 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 /> �.. P Tel phone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov,org/ehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Na ` Report for the month yeaRD-WIT <br /> Company Address: Signature: <br /> Street Address i Ciry Zip Code <br /> All information submitted must be com lete, accurate, and legible <br /> DATE NAME OF BUSINESS ORNADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAL NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED (G) GREASE TRAP FACILITY <br /> PLEASE ICLUDE STREET N, DIRECTION, STREET NAME AND CITY C CHEMICAL. <br /> Ci � <br /> Ci <br /> 1 cilygTOC4M 1 CA 1200 r <br /> gg cit /. <br /> T- IlifrolCt;=—r6rif In1 C . <br /> 2��- <br /> city <br /> Ci <br /> Cit <br /> City <br /> Cit <br /> City <br /> city <br /> F <br /> City <br /> City <br /> Cit <br /> Cit <br /> Cit <br /> city <br /> Ci <br /> Cit <br /> EHD 42-04 y <br /> 11f Septic/Cesspool Report <br />