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y SAN JOAQUIN(AUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by <br /> 600 East Main Street, Stockton,CA 95202-2708 the 12th of each month <br /> P Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> c4�rFOR�� <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: � y <br /> Company Address: �a Report for the mo hof: <br /> Street Address` Signature: / <br /> City Zip Code <br /> All information Submitted must be corn fete, accurate, and legible <br /> DATE NAME OF BUSINESS OR r <br /> PUMPED PROPERTY OWNER ADDRESS WHERE WORT{WAS DONE GALLONS (R) REStDFNTIAL NAME OF TREATMENT <br /> PLEASE INCLUDE STREET p, ,DIRECTION, STREET NAME AND CITY PUMPED (C') GREASE TRAP FACILITY <br /> C CHEMICAL <br /> Ciot wAj rA 00,0 C. �T <br /> '•2 _o � city k C , <br /> z t <br /> AU 'CA a006 , <br /> Ci <br /> Ci <br /> Cit j <br /> Ci <br /> 1 <br /> Cit <br /> Cit <br /> 1 <br /> Ci <br /> Ci <br /> Ci { <br /> Cit I . <br /> Ci <br /> Cit J <br /> Ci { <br /> Ci <br /> Cit <br /> EHD 42-04 <br /> Septic/Cesspool Report <br />