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SAN JOAQUIN C OUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT , Return this form by <br /> ;��. 0 7 Zu0$ 600 East Main Street, Stockton,CA 95202.-2708 ' the 12`'of each month <br /> Telephone:(209)468-3420 Fax:(209)464-0I38 Web:www.sjgov.org/ehd i <br /> �i���Lly t HEALTH � <br /> ENVIR SEPTAGE CLEANER'S REPORT ' <br /> Company Name: Pr' <br /> Re ort for the mouth o : yei U <br /> Company Address: Sig nature• i; r <br /> Street Tddress Ity Zip Code E I, <br /> P <br /> All information submitted must be complete accurate, and legible � <br /> DATE NAME OF BUSINESS OR ( ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAL NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED (G) GREASE TRAP FACILITY <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AlD CI Y C) CHEMICAL <br /> yµ �r .S { + <br /> t <br /> sOc Ci A.; CA 1200 <br /> 77 <br /> el- <br /> iV <br /> ' <br /> city ,, 14 A0060C . 7-i(/ , <br /> (`1 • <br /> CA 9 <br /> 790 C: jff <br /> CitC:;r;t,6rh 70L) <br /> !=—ckAIA' er ,' ind Ci C6ch <br /> Y 9 <br /> e4 7 C S A7Al' <br /> Ci <br /> fel 2 �'r hA cit {i D G <br /> { I cityaclich ce? 5 <br /> nn <br /> /'- citk I <br /> MalbzU)S' ` <br /> r Ci14 r el A j <br /> f "r, City . <br /> 13m oC <br /> Cityzace /6 I <br /> O r D P d cit D T # <br /> 6 At <br /> a ci SC)O n 'f A) F;. <br /> r� 1 r 3 - G� Ci y' <br /> C, RAC <br /> 05 16 r-n Matra rc�A.j 16� e cit f <br /> 6kII)42-04 <br /> Septic/Cesspool Report <br />