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SAN JOAQUIN(AUNTY 0 <br /> z + ENVIRONMENTAL HEALTH DEPARTMENT Return this form by <br /> ` 600 East Main Street, Stockton,CA 95202-2708 the 12th of each month <br /> y Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.orWehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: n1 Repo l for the nth of: year <br /> Company Address: Q S ? Cwt Signa ure: <br /> Street Address City Zip Code _ <br /> All information submitted must be complete, accurate, and legible <br /> I <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE I GALLONS (R� RESIDENTIAL NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED (G) GREASE TRAP FACILITY <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY (C) CHEMICAL <br /> city <br /> City.. <br /> cityI <br /> City <br /> City. <br /> i� <br /> city <br /> µ <br /> City <br /> ' <br /> city <br /> ' <br /> City <br /> city <br /> Cit <br /> r Cit <br /> city <br /> Cit <br /> Cit ' <br /> cit I <br /> Cif <br /> Eft 42-04 <br /> Septic/Cesspool Report <br />