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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 9868 East Hazelton Avenue, Stockton, CA 95205-6232 12th of each month <br /> Telephone:(209) 468-3420 Fax: (209) 464-0938 Web:www,sjgovprg/ehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: �� �l � C-1 Report for the month of:6f year <br /> Company Address: � RoA 22 �- L>� Signature: Any a 6 <br /> 5freef ddress City N463 <br /> 8. <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) GREASE TRAP FACILITY <br /> PLEASE INCLUDE STREET N, DIRECTION, STREET NAME AND CITYC CHEMICAL <br /> " <br /> city <br /> cit <br /> city <br /> Cit E <br /> -ftj VCU <br /> ,._ <br /> 2016 <br /> city <br /> cit <br /> Cel <br /> Lilt <br /> cit <br /> ctt <br /> city <br /> cit <br /> cit <br /> city <br /> ci <br /> cit <br /> cit <br /> Cit <br /> • <br /> city <br /> EHa 42-04 SEPTAGE CLEANERS REPORT <br /> 10/4107 <br />