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SAN JOAQUIN COUNTY — - <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> E,�> 9868 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 /> S PTAGE CLEANER'S REPORT <br /> j -� <br /> Company Name: l� cagjf2o �-'� Report for the month of: �� year <br /> Company Address: '� 3� 5an � �A � Signature: " <br /> Street Addrass cuy Zlp Code <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 0, DIRECTION, STREET NAME AND CITY C1-CHEMICAL <br /> lZ2 1176. crr T' X 1n6 US- T ,c2 RlIck— <br /> Cfty <br /> crr <br /> cit <br /> cit <br /> Ufa, <br /> city T-�r-= <br /> clt <br /> city <br /> city ENVIR'ON11EV 4L <br /> /S Rln ES <br /> crr <br /> city <br /> city <br /> city <br /> cit <br /> city <br /> cit <br /> cit <br /> cit <br /> • C!t <br /> END 42-04 SEPTAGE CLEANERS REPORT <br /> 10/4107 <br />