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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> SAN 1868 East Hazelton Avenue, Stockton, CA 95205-6232 12th of each month <br /> Y.- ;yY,• Telephone:(209) 468-3420 Fax: (209) 464-0138 Web:WWW.sjgovprg/ehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: F-1 CJ4.1'11 10 Lcr�i rl Cc ) Report for the month of: .Marc year ,2( , <br /> Company Address: p�. /)_/3nx y= jn 1) fL�C�f� _ L'( `-f 14 63 Signature: `i I I C'l.l l (C` <br /> Street Address City Zip Code <br /> All information submitted must be complete, accurate and legible <br /> E <br /> ESIDNTIAL <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RNAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED (G) GREASE TRAP FACILITY <br /> PLEASE INCLUDE STREET U, DIRECTION, STREET NAME AND CITY C CHEMICAL <br /> 3 Cil x' II tLjjLn' t 1'71 r 1 citT-e- 'rlq I i l U L)s _ ` LU <br /> city <br /> cit <br /> cit <br /> city <br /> city <br /> cit <br /> city <br /> C =NVI <br /> SPR y <br /> cit _ 1T/ MI 4A� <br /> city <br /> S <br /> city <br /> cit <br /> CIE <br /> city <br /> city <br /> cit <br /> city <br /> • <br /> city <br /> END 42-04 SEPTAGE CLEANERS REPORT <br /> 101407 <br />