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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the the <br /> �< 640 East Main Street,Stockton,CA 952D2-3029 12th of each month <br /> Tefephiane:(209)4613-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: SC-/� ' rt For the month of: .L year <br /> Company Address:a ` `t f <br /> r� Street Address City Zip Code d +y �Mfr+•'':�` <br /> a r <br /> C; All Information submitted must be complete. accurate and legible <br /> DATE. NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R] RESIDENTIAL NAME OF TREATMENT NT <br /> PUMPED PIROPERTYOWNER PUMPED tG] 0WASE TRAP FACILITY <br /> PLEASE INCLUDE STREET p, DIRECTION, STREET NAME AILD CITY C CHEMICAL <br /> APza city <br /> C city <br /> Ci <br /> CITY <br /> C <br /> Cny <br /> G <br /> CRY <br /> Gi <br /> coy <br /> I <br /> Cily <br /> C� <br /> CCi <br /> cily <br /> iimi <br /> Q Ci <br /> cs <br /> d- <br /> City <br /> d+ <br /> City <br /> 0 <br /> o Ci <br /> c� <br /> Cr' citj <br /> 0 <br /> z EHD 42-04 SEPTAGE CLEANERS REPORT T <br /> 1014107 <br />