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SART JOAQUIN COUNTY <br /> } r ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 640 East Main Street, Stockton,CA 95202-3029 12"'of each month <br /> Telephone:(209)468 3428 Fax:(209)464-0138 Web:www.sigov,orglehd <br /> `" (► SEPTAGE CLEANER'S REPORT <br /> Company Dame: <br /> L e o f r year oi� <br /> Company Address: I�WSignature: <br /> r� Ste&Address Ci[y Zip Code %�rt " <br /> Q All information submitted must bo Com Plate, accurate and legible <br /> z DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS {RI RESIDENTIAL NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED tCi) GREASETRAP FACILITY <br /> PLEASE INGLUGE STREET B, DIRECTION, STREET NAME ARD C1TY C CHEMICAL <br /> city <br /> Ci <br /> city <br /> cily <br /> city <br /> Ci <br /> city <br /> cily <br /> elly <br /> Cily <br /> city <br /> cily <br /> city <br /> city <br /> Q <br /> Cily <br /> rn <br /> -- <br /> Cily <br /> rn <br /> Ckty <br /> O <br /> o <br /> Cily <br /> c� <br /> d <br /> EHOk24 SEPTAGE CLEAN ERS REPORT <br /> i914JQT <br />