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SAN .JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> rt 1868 East Hazelton Avenue, Stockton, CA 95205-6232 121h of each month <br /> Telephone:(209) 468-3420 Fax: (209) 464-0138 Web:www.sjgovprg/ehd <br /> SEPTLLAGE CLEANER'S REPORT <br /> Company Name: ^ �\ L C. It Report for the month of: year ` E� <br /> Company Address: OrX S tb0—� Signature: ; <br /> Street Address city Ztp 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 N, DIRECTION, STREET NAME AND CITY C CHEMICAL <br /> cit <br /> Cit <br /> Cit <br /> F: <br /> cityram u r <br /> Cit <br /> city <br /> cit R�'INrq�H <br /> cit <br /> city <br /> city <br /> city <br /> city <br /> cit <br /> CI <br /> Cit <br /> Cit <br /> cit <br /> cit <br /> • <br /> city <br /> EHD 42-04 I h O' 7 Y &) A Qojcy)V-Qj SEPTAGE CLEANERS REPORT <br /> 1014107 <br /> u4� �0 00 <br />