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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.sjgov.org/ehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: C Report for the month of:Vby-6..r,-7-6j,5 <br /> Company Address: d . 60 X C?a3 6an ,`1 Qj Signature: <br /> Street Address City Zip Code <br /> All information submitted must be complete, accurate, and legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS lR} RESIDENTIAL NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED (G) GREASE TRAP FACILITY <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY C CHEMICAL <br /> cit <br /> Cd <br /> city <br /> city <br /> Cit <br /> city RECEIVED <br /> Cit <br /> Ci <br /> PERMIT/SE HEALTH <br /> a <br /> city <br /> city <br /> Cit <br /> Cit <br /> city <br /> Cit <br /> city <br /> Cit <br /> Cit <br /> • <br /> pty <br /> N o ►� h bei <br /> EHD 42-04O I SEPTAGE CLEANERS REPORT <br /> 1014/07 �O e� t(Yl b� <br /> P <br />