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-- SAN JOAQUIN COUNTY _ <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this farm 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.orq/ehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: Report for the month of: <br /> _. ; year <br /> Company Address:_ �)• InC�x L(��� �r � Ity �C� �-� zl c d4UJ Signature: <br /> Street Address <br /> P <br /> All Information submitted must be complete, accurate, and legible <br /> DATE V NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE 4ZLLONS= (R) RESIDENTIAL 8 <br /> PUMPED PROPERTY OWNER (G) GREASE TRAP NAME OF TREATMENT <br /> PLEASE INCLUDE STREET M, DIRECTION, STREET NAME ANDUMPED FACILITY <br /> C CHEMICAL` _— :zs �__� _ <br /> Cit <br /> Cit <br /> i <br /> City _ <br /> CII <br /> CityAY 1 20i5 <br /> Cit <br /> CI PER <br /> I3VICE,c: <br /> Cit <br /> Cit <br /> tat <br /> Cll <br /> Cit <br /> Cit <br /> cit <br /> Cit <br /> Cit <br /> Cit <br /> r <br /> FHn a�.nn t( l�t C'I L-USS C�6"yt �✓c-C< < <br />