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REOFIVED <br /> SAN JOAQUIN COUNTY � <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> EJO East Mein Street, Stockton, CA95202-3029 LN'-;'I'H alt MENV'IFG t t-� 12u'of each month <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sigov,ft/610:f,5� 1 t'.'it <br /> SEPTAGE CLEANER'S REPORT <br /> f <br /> Company Name: Report for the month of: year�a <br /> Company Address: X -�7 Signature: <br /> Stmd Address city rip Code <br /> All information submitted must ba complete, accurate, and legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R► ResmFarrvL NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED (G) GRE&5E TRAP FACILITY <br /> PLEASE INCLUDE STREET /, DIRECTION, STREET NAVE AND CITY C CHEMICAL <br /> lC1 <br /> d <br /> city <br /> I <br /> Uty <br /> i <br /> raty <br /> 3 <br /> c <br /> C <br /> c <br /> ON <br /> CAY <br /> c' <br /> ritu <br /> city <br /> C' <br /> city <br /> _ C <br /> ri <br /> 2 <br /> r-ity <br /> L� <br /> U' <br />� � C <br /> city <br /> n � <br /> CU E'Fi0 42-04 <br /> SEPTAGE GLEANERS REPORT <br /> 1014M <br /> n <br /> Li <br /> L� <br />