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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 12th of each month <br /> . Telephone:(209)468-3420 Fax: (209) 464-0138 Web:www.sjgovprg/ehd <br /> SEPTAGE CLEANER'S REPORT <br /> � G ) �� yy <br /> r ;ompany Name: ej 6f� � �f �t. J Report for the month of: S-CaL'U 1 <br /> Company Address: "V- C c 3 _} s 6-n KaAcrj C�h Signature: <br /> Street Address City Zip Coda's L4 4 6'� <br /> All Information submitted must ba complete, accurate and legible <br /> _1 <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R1 RESIDENTIAL NAME OF TREATMENT <br /> SLUMPED PROPERTY OWNER PUMPED (G) GREASE TRAP FACILITY <br /> PLEASE INCLUDE STREET N, DIRECTION, STREET NAME AND CITY (ClCHEMICAL <br /> Cit <br /> city <br /> cit <br /> Cit <br /> cit <br /> city <br /> city o ONAf�f��TA, <br /> P✓I��S <br /> cir <br /> city <br /> cit <br /> cit <br /> Cff <br /> cit <br /> cit <br /> city <br /> c1t <br /> c1r <br /> city <br /> c <br /> EHo 42-04 V` I TAG�CLEANERS REPORT <br /> 1014A)7 <br />