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RECENED SAN JOAQUIN COUNTY <br /> Z��� EWARONMENTAL HEALTH DEPARTMENT Return this form by the <br /> PR � 5 600 East Main Street, Stockton,CA 95202-3029 �,, .� : le of each month <br /> T ne:(209)468-3420 Fax:(209)4640138 Web:www. "g ef�d ti ' <br /> E T ��ES SEPTAGE CLEANERS REPORT <br /> MMENT <br /> Company Name: Report for the mon f: year <br /> Company Address: - U•6ax Signature: <br /> sheet Add=s city Zip Coes <br /> m <br /> All Information submitted must be com lete, accurate and legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS IR) IE�N� NAME OF TREATMENT <br /> PUMPEDPROPERTY OWNER PUMPED 16) GREASE TRAP <br /> PLEASE INCLUDE STREET ■, DIRECTION, STREET NAME AND CITY C � FACILJTY <br /> G <br /> C <br /> nity <br /> city <br /> C' <br /> CKV <br /> Cky <br /> Cfty <br /> G <br /> O <br /> IY <br /> LL <br /> Q <br /> rAy <br /> lD <br /> I"7 <br /> CS] EHO C' <br /> m <br /> IW4/ <br /> 42-01 <br /> 7OI4f07 SEPTAGE CLEANERS REpCm <br /> i <br /> iZ <br /> Q <br />