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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> aA 1868 East Hazelton Avenue, Stockton, CA 95205-6232 12th of each month <br /> Telephone: 209 468-3420 Fax: 209 464-0138 Web:www.s ov.or /ehd <br /> SEPTAGE CLEANER'S REPORT <br /> [ <br /> Company Name: y11 t v'1C, �C3 �`t- 7 Report for the month of: "IE- � year G <br /> Company Address: i )BOW �= Signature: <br /> S reet Address City Zip Code 4 4/�`,3 <br /> All information submitted must be complete, accurate and legible <br /> �J <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 #, DIRECTION, STREET NAME AND CITY C CHEMICAL <br /> -' i "• <br /> C'�i�Yt(V(G C <br /> 61 , C�l i city 'Te-)r m ?v)cj 3 '7`J To Lk)Q--r f`--1 <br /> city <br /> city <br /> cit <br /> Cit <br /> city <br /> cit <br /> city <br /> city <br /> 1ENT= <br /> cityF r <br /> cit <br /> city <br /> cit <br /> cit <br /> city <br /> city <br /> cit <br /> cit <br /> CLtz <br /> EHD 42-04 SEPTAGE CLEANERS REPORT <br /> 10/4107 <br />