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. _ . SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> kv 1868 East Hazelton Avenue, Stockton, CA 95205-6232 12th of each month <br /> iJ�F Telephone: (209) 468-3420 Fax: (209) 464-0138 Web:www.sjgov.org/ehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: t7n Aoa"1 (21 U'1D p Report for the month of: / �� Q year�I� <br /> Company Address: 2 �C y/C �k�3 -50-n ��cX`i O )(A Signature: <br /> Street Atldress City ° Zip 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) GREASETRAP FACILITY <br /> PLEASE INCLUDE STREET p, DIRECTION, STREET NAME AND CITY C CHEMICAL <br /> City <br /> City <br /> city <br /> city <br /> City <br /> City <br /> City <br /> CITY <br /> CI <br /> s <br /> city IAA, <br /> city <br /> CITY Pon. AL NPA I— <br /> CityI <br /> city <br /> city <br /> city <br /> Ci <br /> Ci <br /> ty <br /> Fye/ //�� Ciity/� �/� <br /> EHO 42-04 "9 ' ` � 1jo, -,,e ' <br /> TN�4107 ��--lMVISA � SEPTAGE CLEANERS REPORT <br /> to O n 0 C- /A,/4U l <br />