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_ D SAN JOAQUIN COUNTY - - <br /> a� ENVIRONMENTAL HEALTH DEPARTMENT Return this form by <br /> t 600 East Main Street, Stockton,CA 95202-2708 the 12n'of each month <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> SEPT,AGE CLEANER'S REPORT <br /> y <br /> Compan ame: Report for the <br /> Comp ny Address: ` v S Signature: — f>� -- <br /> Street ess Zip e E— <br /> All 'nformation submitted must be complete, accurate, and legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAL NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED (G) GREASETRAP FACILITY <br /> PLEASE INCLUDE STREET b, DIRECTION, STREET NAME AND CITY cNEMICAL <br /> _ �/, /C) Ci �� � <br /> t � <br /> 1 " J <br /> Ci <br /> r City <br /> 4g�' city <br /> Ci <br /> / <br /> City <br /> ll r Ci <br /> city <br /> City <br /> city <br /> city <br /> City <br /> Cit <br /> Ci <br /> city <br /> city <br /> City <br /> City <br /> EHD 42-04 SrpnUCesspW1 Repwt <br />