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SAN JOA UIN COUNTY <br /> CNVIRONME:N'1'AL HEALTE4 DEPARTMENT Return this form by <br /> 600 Cast Main Strect,Stockton,CA 95202-2703 the 12`lof each rttot>tth <br /> � �. <br /> Telephare:(209)468-3420 Fax:(209)464-0138 Web:wwW,sjgov.org/ehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: _ Report for the month of• yearR <br /> Company Address: ��j�� S- qw>b _ Signature: <br /> street Address City Zip Codc <br /> All Inrormation submitted must be complete, accurate, and legible <br /> DATE NAME Of BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (Rl t+ESIDENTIAL NAR4E OFTREA'I'MI:NT <br /> M <br /> PUMPED PROPERTY OWNER PUMPED (G) C-RFASETRAP FACILITY <br /> PLEASE INCLUDE STREET H, DIRECTION, STREET NAME AND CITY (C) CIIFIv11CAL <br /> C° ril <br /> rn <br /> 0 <br /> N Cit <br /> ily <br /> Cil <br /> Cily <br /> Ci <br /> city <br /> Cit m <br /> _ _City o <br /> z <br /> Cil <br /> a <br /> 0 <br /> Cil t� <br /> m <br /> City` <br /> Cit <br /> C _ City o <br /> co <br /> Cit <br /> O <br /> Cil <br /> crf <br /> CD Cityt— <br /> to <br /> N � <br /> Cil > <br /> CD City _ <br />('7 <br /> r�- <br /> U <br /> 0 cuD 42.0,1 <br /> ....�__, Scplir/Ccvvponl Rclw,l <br />