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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT r Return this form by <br /> tj 600 East Main Street, Stockton,CA 95202-2708th 12th of each month <br /> �. P• Telephone:(209)468-3420 Fax:(209)464-0138 Web:www-sjgq''•..org/ehd € <br /> '9ClFORtt� � '� ... •F <br /> SEPTAGE CLEANER'S REPORT dl <br /> Company Name: �C.� tA- n # <br /> 1 4 R port for the nth of:1�L .�V� year�! <br /> Company Address: Q F. , _ a� •N r <br /> Signa <br /> ture• <br /> Street Address <br /> City Zip Code <br /> All information submitted most be com lete, accurate, and legible <br /> DATE NAME OF BUSINESS OR k (R) REBID 1+� a-'-. w <br /> PUMPED PROPERTY OWNER ADDRESS WHERE WORK WAS DONE GALLONS NNNE O-RI REATMENT <br /> PLEASEINCLUDE STREET #, DTRECTION, STREET NAME AND CITY PUMPED (G) GREASE FACILITY t <br /> f .7. C CHEMICAL1#100 las4a Lk kd. ,... . <br /> Cit <br /> Lor <br /> Ci 'T r d {� <br /> t ,�. <br /> a ��` =''a City. t, d <br /> 'aQ city <br /> rannJI �y� JJ <br /> �1 �t ' All <br /> / �© �. � m <br /> Ci <br /> 8 !6 e J0 <br /> _ c' �' <br /> 0 l ci t - <br /> . oa � t„ <br /> t o' c <br /> i, � Cit `C.' C+: V` a <br /> 3 t city <br /> ev htAnmz _ <br /> Cit Pt4. <br /> IV <br /> City <br /> t City T �l <br /> kC1 <br /> 'iC Citvdo p A"} J h O <br /> f I <br /> C; � � •, � t <br /> �2 $� .. i <br /> �Q V Cit ' <br /> EUD 42-04 x <br /> i Septic/Cesspool Report <br />