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SAN aJOAQUIN 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 /> SE"P�T�AGE CLEANER'S REPORT <br /> Company Name: �� 11lYl !k7o Oa+ C/C� Report for the month of: V ,0_p-year <br /> Company Address: &x Prl (Ce (�O �, (-A . C7�W63 Signature: <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 /> _ C <br /> cit <br /> El <br /> Cit <br /> Cit <br /> city M TAL HEA.L.-- <br /> PERMIT/Ic ERVICES <br /> City <br /> Cit <br /> city <br /> Cit <br /> Cit <br /> CIt <br /> Cit <br /> Cit <br /> Cil <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> city ,1 <br /> EHD 42.04 p SEPTAGE CLEANERS REPORT <br /> 10/4/07 \J-Lf )0 /3 <br />