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RECEIVEDSAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> SEP 1 2 2��4 1868 East Hazelton Avenue, Stockton, CA 95205-6232 12th of each month <br /> z Telephone: (209) 468-3420 Fax: (209) 464-0138 Web:www.sjgov.org/ehd <br /> ENVIRONMENTAL HEALTH SEPTAGE CLEANER'S REPORT <br /> Company Name: PERM ERrI.P. Iz-C• 2041 JL j ,0 Report for the month of: I I-C,^ year <br /> Company Address: , (� 1 [;' �-CE �jC" ` � ?(� �� ,%� Signature: "22 f <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 GALLON (R) RESIDENTIALS NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED (G) GREASETRAP FACILITY <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY C CHEMICAL <br /> ) Cit PC <br /> LJ <br /> city M <br /> w-1rc ' C Cit t� 5 k ev- PcLrk <br /> Cit <br /> Ct <br /> CII <br /> Cit <br /> Cil <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> CII <br /> Cit <br /> Cit <br /> Ci[ <br /> 0 <br /> EHD 42-04 SEPTAGE CLEANERS REPORT <br /> 10/4/07 <br />