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SAN JQAQUIN COUNTY R EC E" $ E <br /> y ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> a 600 East Main Street,Stockton,CA 95202-3029 l U L 0 8 2011 ie of each month <br /> Telephone:(209)468-3420 Fax:(209)4640138 Web:www.sjgov.orglehd <br /> SEPTAGE CLEANER'S REPORT ENVIRONMENTAL Hmruel <br /> Company Name: - Report ffiv '� year <br /> Company Address: -�- .t Signature: <br /> Street Addn!SS City Zip Code <br /> 00 <br /> All information submitted must be complete, accurate, and legible <br /> DATE !JANE OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS <br /> {R) REsmsNsiAt KAME OF TREATMENT <br /> LD PUMPED PROPERTY OWNER PUMPED {GI GREASE TW <br /> FACILITY <br /> PLEASE INCLUDE STREET *. DiRECTION, STREET HARE AND CITY Lg 0"ICAL e <br /> O { <br /> F— city <br /> G' <br /> CRY <br /> city <br /> City <br /> City <br /> C <br /> city <br /> C" <br /> G" <br /> O city <br /> ry <br /> cft <br /> LL <br /> CD <br /> city <br /> r+ citi <br /> m <br /> N <br /> i <br /> EM 62-04 SEPTAGE CLEARERS REPORT <br /> � 1014107 <br /> h , <br />