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SAN JOAQUIN COUNTY <br /> �• ENVIRONMENTAL.HEALTH DEPARTMENT Return this form by <br /> 600 East Main Street, Stockton,CA 95202-2708 the 12"hof each month <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/chd <br /> gcr�o�a SEPTAGE CLEANER'S REPORT <br /> Company Name: Report for the th ye 217— <br /> i <br /> Company Address: C { Signature: <br /> Street Address City Zip Code <br /> All information submitted must be com fete, 314urate, and legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) REsnDENTIAL NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED (G) GREASE TRAP FACILITY <br /> PLEASE INCLUDE $TAFFY #, DIRECTION, STREET NAME AND CITY {C) CHEMICAL <br /> - <br /> " �I i l ' Z city <br /> City <br /> Cit <br /> i FT Cit <br /> f <br /> City <br /> r <br /> 1 <br /> City <br /> City <br /> city <br /> Cit <br /> Cit <br /> } <br /> city <br /> City <br /> City <br /> City <br /> city <br /> Cit <br /> City <br /> City <br /> Ci[ <br /> EHD 42-04 Septic/Cesspool Report <br />