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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> T, r 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: m i 3&i f r_f L, o Report for the month of: year �4, 1 <br /> Company Address: Q C(6z� S'y:,l �'1�i`(cc c,; aL14(u5 Signature: `'r <br /> Street dress 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 /> 1 t �:I 1►1v acth tilt t a Cit -m Ccs 5, T FJG✓cin 7 �����. <br /> ",r ` c ff t% C 'a C L.._ Cit r�.i't t% <br /> , , <br /> Cit <br /> Cit <br /> Cit <br /> City RE <br /> Cit <br /> J <br /> Cit <br /> City ENVIRONMENTAL HEALTH) <br /> P <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> City <br /> Cit <br /> Cit <br /> Ci[ <br /> EHD 42-04 SEPTAGE CLEANERS REPORT <br /> 10/4/07 <br />