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> �U=r`'r'• SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL I-IEALTN DEPARTMENT Return this form by <br /> 600 East Main Street,Stockton, CA 95202-2708 the 12t1'of each mouth <br /> Telephone:(209)468-3420 Fox:(209)464-0138 Web:www.sjgov.org/elid <br /> SA <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: I'\ Report for the month p� _ ycailaly <br /> Company Address: T Signature: <br /> Sheet Address City Zip Codc <br /> All information submitted must be com lege, accurnle, and legible <br /> L0 DATE NAME Of BUSINIESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAL NANTE OFIMEATMENT <br /> r� PUMPED PROPER'rYOWNER PUMPED (G) GREASE•rItAl' FACILITY <br /> INCLUDE STREET k, DIRECTION, STREET NANIE AND cT'rY (C) CHEMICAL <br /> O <br /> t� <br /> m Cil <br /> rn <br /> O <br /> N -- City <br /> —- by <br /> c;t <br /> Cil <br /> Ci <br /> city <br /> —-- Cit <br /> - d- <br /> Cil o <br /> Cil <br /> 0 <br /> rte, <br /> Cit <br /> cn <br /> Cil <br /> � o <br /> co Cil c� <br /> c _ Cit <br /> � m <br /> co <br /> Cil <br /> O <br /> Cit <br /> ca — <br /> t j Cit ~ <br /> N <br /> C;I <br /> O Cit aV <br /> ch cl:f <br /> U <br /> 0 li110 42-04 ScImic/Cesspool Repott <br />