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SAN JOAQUIN COUNTY <br /> :x 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.orglehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: ` I L m lfln P) ) r-� ('1 jl h Report for the month of: year <br /> Company Address: X0-0 "a- , C q�403 Signature: �a LIi CE_ !� <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 CItTYii C CHEMICAL <br /> CICr�► dC�xt C r C " Cit I r�VV'� -7J ' ' Lam' J <br /> 1 c� l 1 Cit 1 � I 1 -� ti <br /> cit <br /> cit <br /> cit <br /> city <br /> cit <br /> ar <br /> 2015 <br /> city 61jIRDj 4mphm.. <br /> cit I rISERVICES <br /> cit <br /> Cit <br /> Cit <br /> city <br /> Cit <br /> Cit <br /> cit <br /> cit <br /> Cit <br /> END 42-04 SEPTAGE CLEANERS REPORT <br /> 10/4/07 <br />