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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENTReturn this form by the <br /> 600 East Main Street, Stockton,CA 95202-3029 �% 12k'of each month <br /> ? Telephone.(209)468-3420 FaX:(209)464-4138 Web:www.sjgov. d <br /> SEPTAGE CLEANERS REPORT <br /> Company Name: . AL Report for the month of: year <br /> Company Address: Ail kAfv� "Li Signature: + � <br /> +� 5lreatJWdress Cr7y Zrp Coda <br /> o , <br /> All Information submitted must ba com feta accurate and legible <br /> HATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS �R) RESIDENTIAL NAME OFTREATMENT <br /> PUMPED PROPERTYCWNER PUMPED tG� GREASE TRAP FACILITY <br /> PLEASE INCLUDE STREET N, DIRECTION, STREET NAME AND CITY C CHEIMCAL <br /> city <br /> C ciLy <br /> cjty <br /> City <br /> city <br /> city <br /> ci <br /> city <br /> ch <br /> city <br /> City <br /> Cily <br /> ¢ <br /> city <br /> city <br /> o. <br /> City <br /> 0 <br /> 0 <br /> N Ci <br /> c i <br /> CILY <br /> c� <br /> U <br /> EHD 42-04 SEPTAGE GLEANERS REPORT <br /> T014107 <br />