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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: L'; -�Ls�N)-mtAo C Report for the month of: H • year <br /> Company Address: )r R. Q(4 Signature: :L" a et e---41 3c <br /> Street Address City Zip Codc, <br /> All Information submitted must be complete, accurate, and legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS RESIDENTIAL NAME OF TREATMENT <br /> —PUMPED PROPERTY OWNER PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY PUMPED (G) GREASE TRAP FACILITY <br /> (C) CHEMICAL <br /> ' 1r, <br /> borl 4 "!, Cb 6�144o"inn LXV-f- CRY 4;,r <br /> C <br /> (-nxv-. i"7,3 io'-i,�' C!"l- Jooje-f fieyl< <br /> City <br /> City <br /> City <br /> City PC[ 1. <br /> City <br /> City <br /> City <br /> City <br /> City <br /> City <br /> City <br /> City <br /> City <br /> City <br /> City <br /> City <br /> EI-ID 42-04 SEPTAGE CLEANERS REPORT <br /> 10/4/07 <br />