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RECEVED <br /> SAN JOAQUIN COUNTY <br /> �. 2 2 Z010 ENVIRONMENTAL HEALTH DEPARTMENT ERIreturn this form by the <br /> r 6DO East Main Street, Stockton, CA 95202-3029 g12kh of each month <br /> o ENVIRl1Nt ENT HEA�Th6,-Phone:(209)468-3420 Fax. (209)�46�4-013B-Web: www.sjgovbr 1 i� p <br /> ...,.�. <br /> ��PMMSERVICES SEPTAGE CLEANER'S REPORT <br /> Company Name: <br /> Report for the month of;, year ` <br /> Company Address: �2l '``� �' 11r7,� _ Signature: <br /> — Street Address City Zip Code11 <br /> z All Information submitted must be com late accurate and la ibls <br /> DATE NAME:OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS [IRI REBIOEN 1411 NAME OF TREATMENT <br /> PUMPED PROPERTYDWNER PUMPED IC GREASETRAP FACILITY <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY G CHEIACRL <br /> CC' <br /> { C' <br /> CKY <br /> c <br /> CHY <br /> CRY <br /> C <br /> C• <br /> C <br /> C. <br /> G- <br /> ity <br /> �..I C <br /> cly <br /> C Ky <br /> Q C' <br /> c� <br /> rn <br /> CKY <br /> 6Cttlf <br /> O <br /> �+ ity <br /> C-4 r-fty <br /> n� <br /> EHD 42.04 SEPTAGE CLEANERS REPORT <br /> 1014107 <br />