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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 /> " SEPTAGE CLEANER'S REPORT <br /> Company Name: rl cainwo Report for the month of:� ear <br /> Company Address: n 90 X n 446A% <br /> nature: <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 9, DIRECTION, STREET NAME AND CITY /f C CHEMICAL <br /> co <br /> Cit F <br /> CII ',� - -d, <br /> Cit 4. <br /> City NOV 2 0 2013 <br /> city I;hn1JI2nAjAAM&1—%t <br /> city <br /> PERMIT/SERVICES <br /> City <br /> Cit <br /> Cit <br /> Cit <br /> Cil <br /> City <br /> City <br /> cit <br /> Cit <br /> Cit <br /> cit <br /> Cit <br /> EHD 42-04 SEPTAGE CLEANERS REPORT <br /> 10/4/07 <br />