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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,S/govprg1ehd <br /> SEPTAGE CLEANER'S REPORT N C,V ZM�OQr <br /> Cri M I 1'�In Uh year <br /> Company Name: Report for the month of., (�k�y <br /> Company Address: (3 'S Signature: <br /> Street Address City Z1p Code <br /> All Information submitted must be complete, accurate, and leglb,le <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 /> 121 <br /> city Te-y M I no CS Jn 100 WQW, <br /> lit MY <br /> Vc1tv <br /> city <br /> at <br /> city 0% <br /> city <br /> C/1y VEC )n" <br /> twvj' , 'Vjv <br /> N\city <br /> city <br /> Clty <br /> city <br /> City <br /> city <br /> city <br /> city <br /> city <br /> C* <br /> EHD 42-04 SEPTAGE CLEANERS REPORT <br /> 1014107 <br />