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SAN JOAQUIN 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: ,�� �i YI �l � [3� ( �c��) Report for the month of: year I <br /> Company Address: t/, J'�C3lC � «.yl �'�Cs��r ; �'�_C�q Signature: <br /> Street Address City Zip Code CT— <br /> All information submitted must be complete, accurate, and legible <br /> DATE NAME OF BUSINESS OR (R) RESIDENTIAL <br /> ADDRESS WHERE WORK WAS DONE GALLONS NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED (G) GREASE TRAP FACILITY <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY C CHEMICAL <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> CII <br /> CII <br /> Ci[ <br /> city <br /> Cit <br /> Ci[ <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> EHD 42-04 SEPTAGE CLEANERS REPORT <br /> 10i4i07 O " -41 Q 'a c. I, r <br />