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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 DEC <br /> Company Name: �' O Rep ��t� of: U V. yea r,--2(ll <br /> Company Address: p G . BOX S C � M (u - o Signature F CU ',jA' _{QU e lj :;, <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 /> Cit <br /> Cil <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> City � <br /> EHD v, Q 1 t ha� p <br /> lo�-1 I <br /> 10!4/07 e rn� �� Gv�xn1a..� SEPTAGE CLEANERS REPORT <br /> �a r � � ��- � <br />