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SAN JOAQUIN COUNTY <br /> c <br /> e' ENVIRONMENTAL( EALTH DLPARTMENT y <I HReturn this form by <br /> 600 East Main Street, Stockton,CA 95202-2708 the 12th of each month <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> LIFOP <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: Report for th onth of: ye�L_ <br /> Company Address: / Signature:.. <br /> Street Address ode <br /> All <br /> All information submitted must be coo lete, accurate, and legible <br /> DA IT NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAL NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED tG) cREnsEne FACILITY <br /> (C) CHEASETR TR <br /> PLEASE INCLUDE STREET 4, DIRECTION, STREET NAME AND CITY <br /> gJl aICAL <br /> ity <br /> op S <br /> �l/ G- • 3 / Ci . ' ` � <br /> Cit <br /> Coy 57''ON <br /> � t <br /> L / City <br /> C1 <br /> — Cit <br /> a <br /> aro f' <br /> S vt/ `ZSd S� <br /> On <br /> city <br /> GOO Cny O <br /> City <br /> 2 s <br /> ityo <br /> �^ d <br /> CiN od �y <br /> O ON <br /> City <br /> EHD 42-04 <br /> -'-'---' Septic/Cesspool Report <br />