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m SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this forth by the <br /> 600 East Main Street, Stockton, CA 95202-3029 32'h of each month <br /> Telephone:(2G9)468-3420 Fax:(20 9)464-0138 Web:www.sjgov.org/ehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: Report for the mont of: year <br /> Company Address: G� G J- r Signature: <br /> S1t Addiezz City Zip Code If <br /> All Informatlnn submitted must be complete, accurate, and legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (Rl ResaxENruu NAME OF TREATMENT _ <br /> J1IMPED PROPERTY OWNER PUMPED (G) GRFJtSETRAP FACILITY <br /> PLEASE INCLUDE STREET 0, DIRECTION, STREET HAMS AND CITY (C) CNE34CAL <br /> W D C itf <br /> L <br /> City <br /> W <br /> co city <br /> cL <br /> io <br /> W <br /> cL <br /> city <br /> } <br /> r' <br /> city <br /> City <br /> city �r <br /> � � z <br /> ily <br /> c <br /> m .j m <br /> CAY <br /> u� fIJ <br /> U) <br /> v <br /> OD ,_c, <br /> m <br /> CD o <br /> N City c-4 <br /> city <br /> o� <br /> LD <br /> v <br /> city <br /> a <br /> N ct <br /> CD <br /> city <br /> a> <br /> I— <br /> m <br /> N <br /> city <br /> CD — <br /> v END 42-04 <br /> m i0141d7 SEPTAGE CLEANERS REPORT <br />