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;. .. SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> tel .' 1868 East Hazelton Avenue, Stockton, CA 95205-6232 12th of each month <br /> �u A Telephone: (209) 468-3420 Fax: (209) 464-0138 Web:www.sjgov.orglehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: I C,am t Yi() 0-r c i U-b Report for the month of: r-)2-C. year 26 <br /> Company Address: tri �_3 Sc+n_ P 1C1�FC� ,( .�� �} Signature: IM a t ). . 6Y1 PJYf:7 <br /> Streel Address Ciry � Lp Code <br /> All information 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) GREASE TRAP FACILITY <br /> PLEASE INCLUDE STREET p. DIRECTION, STREET NAME AND CITY C CHEMICAL <br /> CI <br /> Cil <br /> City <br /> City <br /> Cit <br /> City <br /> Cit <br /> Cit <br /> City <br /> Cit 2 <br /> City <br /> city <br /> ENVISONM NTA FAVICES <br /> ci <br /> City <br /> Ci <br /> City <br /> city <br /> city <br /> ty <br /> Ci <br /> EHD 42-04 <br /> 10/4/07 SEPTAGE CLEANERS REPORT <br /> moh�-h b� Der' - :�o ► a. <br />