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TIr <br /> �o 1, �.w SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT 1r RID �� � U turn this form by <br /> 600 East Main Street, Stockton,CA 95202-2708' the 12`"of each month <br /> x:Telephone:(209)468-3420 Fax:(209}464-0138 Web:www.sjgov.grg/ehd 13 z0Q + <br /> 4�fFpRT�� C'E r <br /> AUG I <br /> SEPTAGE CLEANER'S REPORT ALTH I' <br /> Company Name. !�,� <br /> Report for the p ��f ye <br /> Company Address: r <br /> 1S. Signature• <br /> Street Address city Zip Code 121, <br /> r ! <br /> A <br /> All information submitted must be caul plete, accurate, and legible rk <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) REsmE L _ N 4141E OF TREATMENT <br /> PUMPED PROPERTY OWNER t'9 I PUMPED (G) GM&TRAP-`R FACILITY <br /> PLEASE INCLUDE STREET k, DIRECTION, STREET NAME AND CITYH (C) CHEMICAL <br /> cid"' Q <br /> -� - Tie v. <br /> Ci <br /> —6j- a U . City. <br /> city j- <br /> 922 , <br /> � G <br /> I ` � cit l-. <br /> - ir"r 3 r " O . <br /> ci t1; <br /> 1 Cit 5 It <br /> c, Po nc Pd <br /> Ci '! <br /> I <br /> 1 Ci y <br /> ci, C s T <br /> 8 SCJ c; w ow1 <br /> I Q ha cit,53 ZD CX10LI <br /> P ' E <br /> 700 3�� d Cit C l^ 2- J��a �+� 1 <br /> We," 11Q ,f0' ('I cit d -r-M C 13 '5 7[ A- <br /> EHD 42-04 <br /> -"----• "++• !' - Septic/Cesspool Report <br />