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77 <br /> ctit SAN JOAQUIN(AUNTY <br /> 1 ENVIRONMENTAL HEALTH DEPARTMENT Return this form by <br /> 600 East Maine Street, Stockton,CA 95202-2708l the 12th of each month <br /> ' Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.orehd <br /> 4Cr�0R�`Q 1 <br /> SEPTE CLEANER'S REPORT ' <br /> Company Name: Repo for the mooth of: yea <br /> Company Address: C• Signature: it <br /> Street Address City Zip Code <br /> All information submitted must be complete, accurate, and legible <br /> DATE NAME OF BUSINESS OR ii ADDRESS WHERE WORK WAS DONE GALLONS RESIDENTIAL NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED (G) GREASE TRAP FACILITY <br /> PLEASE INCLUDE STREET k, DIRECTION, STREET NAME AND CITY C CHEMICAL <br /> e Ci QQ <br /> h Ci <br /> ty <br /> a . <br /> f <br /> Cit ' <br /> I <br /> City <br /> cit <br /> " C <br /> ity <br /> I Cit <br /> City <br /> _ Cit •1 <br /> Ci[ <br /> city <br /> City <br /> city <br /> City <br /> Ci , - <br /> Cit { <br /> City <br /> t <br /> r� <br /> city <br /> Cit <br /> ti <br /> EIID 42-04 Septic/Cesspool Report <br />