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Q SAN JOAQUIN(COUNnr.-,)f°r `� I�E <br /> ENVIRONMENTAL HEALTH DEPARTP4 INTI Return this form f y the <br /> r, 600 East Main Street,Stockton, CA 95202-3029 O 4 1 �IU 12"'of each month <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.arke <br /> s� SEPTAGE CLEANER'S REPORT ENVIRONMENT HEALTH <br /> Company Name: Repar�tEar� 'li 5 year <br /> Company Address: U D a (/� 4� Signature: <br /> creel Address City Zip Code <br /> !S] All information submitted must bo complete, accurate, and legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAL NAME OF TREATMENT <br /> m PUMPED PROPERTYOWNER PUMPED (G) GREASE TRAP FACILITY <br /> PLEASE INCLUDE STREET $, DIRECTION, STREET NAME ANO CITY C 04EMICAL <br /> D <br /> C] 1 <br /> G. <br /> t' <br /> city <br /> city <br /> city <br /> CRY <br /> City <br /> C' <br /> My <br /> city <br /> CjIv <br /> E <br /> O <br /> CIN <br /> (Y <br /> Lr. <br /> Cr <br /> 0) CRY <br /> P'1 <br /> CD C <br /> z-r <br /> m <br /> city <br /> N <br /> CU EHD 42-04 <br /> �t 1014E 7 SEPTAGE CLEANERS REFoRT <br /> I <br /> Cr <br />