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CI7-& <br /> AN JOAQUIN COUNTY <br /> ENVIR MENTAL HEALTH DEPARTMENT Return this farm by the <br /> 600 East Main Street,Stockton, CA 95202-3029NTER 1 �'of each month <br /> Telephone:(209)458-3420 Fax:(209)464-0138 Web:www.9jgov.orgle d K v <br /> SEPTAGE CLEANER'S REPORT ,q <br /> Company Name: Report for the month of , yearf/ : <br /> Company Address: Signature: <br /> Streei Address City Zip Code <br /> p <br /> z <br /> All Information submitted most be complete, accurate and legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS lR} RESIDENTIAL NAME OF TREATMENT <br /> PUMPED PROPERTY4WNER PUMPED (G') GREASETRAP FACILITY <br /> PLEASE INCLIIOE STREET N. dIRECTION, STREET HANE AND CITY C CHEMICAL <br /> C Es <br /> ' 1 <br /> C <br /> CN <br /> Cil <br /> city <br /> Ci <br /> Cii <br /> Cily <br /> city <br /> C- <br /> v 5 <br /> a C- <br /> C-1 <br /> ti \ <br /> [�E C. <br /> T <br /> city <br /> I <br /> C <br /> F-HD 42-D4 SEPTAGECLEANERS REPORT <br /> WOW <br />