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SAN JOAQUIN COUNTY <br /> 2 � ENVIRONMENTAL HEALTH DEPARTMENT Return this form by <br /> �elephone: <br /> 600 East Main Street, Stockton,CA 95202-2708 the 12''of each month <br /> (209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: Report for the onth of y <br /> Company Address: (S Signature: <br /> Street Address City Zip Code <br /> All information submitted must be complete, accurate, and le ible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAL TREATMENT <br /> TRE <br /> NAME OF <br /> PUMPED PROPERTY OWNER PUMPED (G) cREAse TRAP OF TRE Y <br /> PLEASE'i INCLUDE STREET k, DIRECTION, STREET NAME AND CITY (C) CHEMICAL <br /> City <br /> �—ec - ze <br /> Ci <br /> �" i ' City <br /> Ci S <br /> r 9 CiOQ <br /> cily .� 10 <br /> city <br /> Ci <br /> Cit <br /> Ci <br /> city <br /> Ci <br /> c <br /> city <br /> city <br /> Ci <br /> city <br /> EHD 42-04 Septic/Cesspwl Repo" <br /> I <br /> Y ' <br />