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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: Gf J9 Report for the month of: 3'a r► ear_;Z Off <br /> Company Address: 1p, D T,O)c 19 a 3 San /h C,�- q tf 0 , Signature: <br /> Street Address City Zip Code <br /> All Information submitted must be com late accurate and lleclible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAL <br /> PUMPED PROPERTY OWNER NAME OF TREATMENT <br /> PUMPED (G) GREASE TRAP FACILITY <br /> _ x V PLEASE INCLUDE STREET N, DIRECTION, STREET NAME AND CITY C CHEMICAL <br /> Ch <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> cit <br /> City FEB3 2015 <br /> Cit <br /> cit <br /> PFRMI /SERV! LTA <br /> City <br /> City <br /> cit <br /> Cit <br /> cit <br /> City <br /> Cit <br /> Cit <br /> Cit <br /> Ci <br /> DID 42-04 , r <br /> 10/4/07 ' �J © �� SEPTAGE CLEANERS REPORT <br />