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RECEIVED .k .. <br /> Q SAN JQAQUfN COUNTY <br /> $ 2015 <br /> ` ENVIRONMENTAL HEALTH DEPARTMENT Retum this form by the <br /> w 600 East Main Street, Stockton, CA 95202-3029 le of each month <br /> `I _ ENVIRONMENTALHEAL'Telephorre: (209)468-342D Fax:(209)464-0138 Web:www.sjgov.ofgfehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: Report for the mo th of: year <br /> Company.Addres sx Signature: <br /> Street Address City Tip Code <br /> AIF information submitted must be com Tete, accurate, and le Ible <br /> DATE NAM);OF BU51H>=5S OR (R) s <br /> ADDRESS WHERE-WORK WAS DONE 13ALLONS NAME OF TREAT6i1ERT <br /> -�fAIPED PROPERTY OWNER PUhIPED (G) GREASE TRAP FACILITY <br /> PLEASE ENCIUD[3 STREET ?, DIRECTION, STREET NAME AND CITY C CHEWAL <br /> w <br /> I <br /> Ld il <br /> W C <br /> f— <br /> (n <br /> <=I <br /> co C rly <br /> W <br /> t— <br /> Q Clt <br /> City <br /> city <br /> citya <br /> city <br /> 0 <br /> Qtyz <br /> CirtyQ <br /> ® i / m <br /> LoCity <br /> . <br /> L0 <br /> v <br /> co Ci L<, <br /> O� <br /> (S) o <br /> N c� <br /> cirym <br /> N <br /> N <br /> city <br /> N � <br /> CD <br /> cityn� <br /> E <br /> CQ <br /> Cit <br /> m <br /> N a <br /> a� <br /> OJ City <br /> m -- <br /> a� <br /> CD EHD 42-04 SEPTAGE CLEA,4ERS REPORT <br /> 1014M 7 <br /> ■ ■ ■ ■ ■ <br /> ■ ■ ■ ■ ■ <br />