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SAN JOAQUIN COUNTY <br /> -�` ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 600 f=ast Main Street,Stockton, CA 95202-3029 42t"of each month <br /> Telephone.(209)468-3420 Fax. v,� <br /> (209)464-0138 Web: ww.sjgov.orgfehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: D --.�� r�i� t _ fo> Pia onth of: year <br /> Company Address: "� - Sign u_re: r '_ <br /> r� Street Address City Zip Code <br /> o . <br /> o All Information SubmittDd must be complete, accurate and le iblo <br /> z <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLO14S (R) RESIDENTIAL NAME OP TREATMENT <br /> PLUMPED PROPERTY OWNER PUMPED (G) GREASETRAP FACILITY <br /> PLEASE INCLUDE STREET 0, DIRECTION, STREET NAME AND CITY C 0HEMICAL <br /> Ci <br /> Citf <br /> city <br /> Ci <br /> Cily <br /> Ci <br /> city <br /> C" <br /> City <br /> city <br /> CRY, <br /> J C <br /> C" <br /> �c <br /> cjty <br /> O <br /> 1_f l <br /> a. <br /> city <br /> city <br /> city <br /> 0 <br /> z EHO 42-04 SEPTAGE CLEANERS REPORT <br /> 111!4107 <br />