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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: c I Camino b Oaf- U.0 Report for the month of: 12 �fo a0ear aC') I4 <br /> Company Address: P. () . X Q . SC1�� ("�� ��1 �( Signature: 'MCUUa (9G2( <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 (GI GREASE TRAP FACILITY <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY C CHEMICAL <br /> i3 L CiXn lYl <br /> Cit Tv- m Joo l ow xPax K <br /> Cit <br /> Cit <br /> city <br /> Cit <br /> City <br /> City ENVIF IONMENTAL HEALTt <br /> Cit <br /> Cit <br /> Cit <br /> Cil <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cil <br /> Cit <br /> E11D 42-04 SEPTAGE CLEANERS REPORT <br /> 10/4/07 <br />