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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 /> ,y Telephone: (209) 468-3420 Fax: (209) 464-0138 Web:www.sjgov.org/ehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: Ci n i V7 d D()-a+ 0 lk b Report for the month of: �� l,1(3�year � <br /> Company Address: ( _ e) X: qX6 cJo-AA � C� C ( �f D Signature: "j)'t CIuL,�(11 <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 /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> City <br /> M NT,,t <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Ci[ <br /> Cit <br /> Cit <br /> Cit <br /> city <br /> Cit <br /> Cit <br /> Cit <br /> EHD 42-04 SEPTAGE CLEANERS REPORT <br /> 10/4/07 <br />