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!.Y SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> j, 1868 East Hazelton Avenue, Stockton, CA 95205-6232 12th of each month <br /> ,n Telephone: (209) 468-3420 Fax:(209) 464-0138 Web: www.sjgov.org/ehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: , nrJ\J� } <br /> �_C.�I"1)1/�(' C �� (� Report for the month of: Vear j . <br /> Company Address: _ r_ O, � �X �fc, 3 Sall Mnck- -) ggt4c 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 (R) 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 /> Cit <br /> Cit <br /> Cit <br /> city DEC 7 <br /> ZQ15 <br /> cit �JV1gpNM <br /> 1 <br /> city Tjs VICE L-rf j <br /> cit <br /> cit <br /> city <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> cit <br /> EHD 42-04 <br /> (�)� I t I i � � 1 r ' End SEPTAGE CLEANERS REPORT <br /> 10/4/07 <br /> a ( NOV , 10 )6 <br />