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r <br /> RECEIVED <br /> x o SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT MAR 0 g 2011 Return this form by the <br /> 600 East Main Street,Stockton, CA 95202-3029 le of each month <br /> C- Telephone:(20 9)468-3420 Fax:(209)464-0138 Web:www.sjr ehd <br /> MOMMENTAL HEAL O <br /> SEPTAGE CLEANER'S REPORT PERMIT/SERVICEg <br /> Company Name: or ' <br /> Report for the nth f: year L <br /> Company Address: Signature: <br /> Scree!A rens 01 ZA Code <br /> �O <br /> All information submitted must be complete, accurate, and legible <br /> M <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDE)MAL NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED iGf GREASETRAP FACILITY <br /> PLEASE INCLUDE STREET X. DIRECTION. STREET NAME AND CITY ICA c1EEMOCAL <br /> O � <br /> F' C' <br /> C- <br /> city <br /> CRY <br /> C <br /> C <br /> city <br /> citv <br /> C' <br /> C- <br /> F <br /> O <br /> LL cay <br /> C <br /> ON <br /> Ln <br /> Ln <br /> r3i <br /> CRY <br /> CRY <br /> i9 <br /> a, EM 42-04 <br /> C� 101407 SEP7`A8E CLEANERS REPORT <br />