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SAN JOAQUIN COUNTY RECEIVED <br /> - ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6291 T 15 2014 <br /> - . Telephone: (209) 468-3420 Fax: Return this form by the <br /> (209) 464-0138 Web:WWw.sjgov.org/ehd 12th of each month <br /> Company Name: -0SEPTAGE CLEANER'S REPORT ENVIRONMENTAL HEALTH <br /> Company Address: <br /> C PERMIT,/SERVICES <br /> Q <br /> • 4M Report for the month of: <br /> Street Address r 0 JL4 <br /> must be com Zi Coodede <br /> All Information submittod late <br /> city Signature: <br /> DATE NAME OF BUSINESS OR accurate, and le Ible ge4g03 <br /> PUMPED PROPERTY OWNER ADDRESS WHERE WORK WAS DONE <br /> ` / PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY GALLONS (R) RESIDENTIAL <br /> C� �L {� PUMPED (G) GREASE TRAP NAME OF TREATMENT <br /> • z j C C CHEMICAL FACILITY <br /> Q � ! O �! a cit 1'1.0 I 0� <br /> 28 !y 1 cit 5 <br /> o� a lc,c.l� Cit T 1�0.r <br /> 1 V�0 50 -7— � <br /> Cit <br /> cit <br /> Clt <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> pit <br /> cit <br /> Clt <br /> CII <br /> Cit <br /> Cit <br /> Cif <br /> Cit <br /> EHD 42-04 <br /> 10/4/07 <br />