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�aG SAN JOAQUIN(AUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT ' Return this form by <br /> i 600 East Main Street, Stockton,CA 95202-2708 the 12Ee of each month <br /> Telephone.(209)468-3420 Fax.(209)464-0138 Web:www.sjgovrg/ehd <br /> f+• ,p <br /> R�EFOR�' SEPTAGE CLEANER'S REPORT <br /> Company Name: eidnara- S L"VAA '' QI Report forthe nth of: -_,` year <br /> Company Address. b o� Sig ature• <br /> Street Address Ci <br /> # ty Zip Code <br /> All information submitted must be complete,accurate, and legible <br /> DATE NAME OF BUSINESS OR i' ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAL NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED (G) GREASE TRAP FACILITY <br /> PL EASE,INCLUDE STREET N, DIRECTION, STREET NAME AND CITY,. C) CHEMICAL <br /> z <br /> cit A <br /> jP 1 Cilysmockm A2 <br /> pit cfe ,v4o <br /> Ci t <br /> CityI' <br /> city <br /> city {i! <br /> city <br /> Cit <br /> city <br /> City <br /> City <br /> Cit <br /> d <br /> City <br /> City , <br /> city <br /> 2 <br /> city <br /> ; <br /> 4 Cit <br /> E}ii3 42-04 <br /> Septic/Cesspool Report <br />