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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> I a 1868 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 /> / SEPTAGE1 CLEANER'S REPORT <br /> ,company Name: f:`! y Y 1�'�� � �a IL7 'l Report for the month of: r '� year�. <br /> Company Address: a7 �'� Signature:` a n ''"C , <br /> Street-Address City I Zip Code <br /> All information submitted must be com tete, 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 /> f PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY C CHEMICAL <br /> �^1 cit <br /> city <br /> cit P' <br /> city <br /> city <br /> "" HEALTF; <br /> cityE'ER iT/,SER <br /> cit <br /> ci <br /> cit <br /> cit <br /> Ci <br /> cit <br /> Cit <br /> city <br /> city <br /> Cit <br /> cit <br /> • ci <br /> END 42-04 SEPTAGE CLEANERS REPORT <br /> 10/4/07 <br />