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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.sjgo%,iprg/ehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: ~� �r'��"�1 i G'Jn ��r� � �'�C c,.� Report for the month of: � year- 2Z� <br /> Company Address: L 6n 3 4 Ck- e q4�JL3 Signature: CD <br /> Street Address T City Zip Code <br /> Alii 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 A, DIRECTION, STREET NAME AND CITY C CHEMICAL <br /> , city <br /> 13 city r T )-5 O t <br /> Cit <br /> city <br /> city <br /> Cit L' x <br /> City LL <br /> G!! <br /> cityE%!TA! <br /> ,r <br /> chty <br /> Cit <br /> city <br /> Clt <br /> Cit <br /> city <br /> C <br /> Cit <br /> Cit <br /> • CI <br /> EHD 42-04 SEPTAGE CLEANERS REPORT <br /> 1014107 <br />