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q I SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> p & O East Main Street, Stockton, CA 95202-3029 12to of each month <br /> Telephone;(209)468-3420 Fax:(209) 464-0138 Web:www.sjgov.org/chd <br /> y}� SEPTAGE CLEANER'S REPORT <br /> [// <br /> Company Name: _ � ��__(`o" Report for the mo th of: Of <br /> Company Address: - r /1-fSignature: <br /> Street Address City Tip Coda <br /> Aft information submitted must be complete, accurate, and legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS tR) RFsm1 NT!>tL NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED (G) roe"ETRAP FACILITY <br /> IT 40 PLEASE INCLUDE STREET N. DIRECTION, STREET NAME AND CITY c d{ ,µ" <br /> O <br /> city <br /> C' <br /> C" <br /> city <br /> C <br /> city <br /> City <br /> city <br /> city <br /> C' 'ERMTqtr• <br /> C <br /> CAV <br /> CA <br /> C' <br /> C] <br /> 1z <br /> U city <br /> CL <br /> -D City <br /> �.1 <br /> RJ C <br /> .-a <br /> C", <br /> CU <br /> EHO 42-134 SEPTAGE CLEAXERS REPORT <br /> 1014W <br /> V <br /> C! <br /> l <br /> l <br />