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u RECEIVED <br /> SAN JOAQUIN COUNTY <br /> JUN 0 4 2014 ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 600 East Main Street, to <br /> eet Stockton CA 95 <br /> 202-3029 <br /> 12 of each <br /> month <br /> Telephone:(209)468-3420 Fax:(209)4640138 Web:www.sjgov_org/ehd <br /> ENVIRONMENTAL HEALTH <br /> Ei�/SERVIC S SEPTAGE CLEANER'S REPORT <br /> Company Name: Report for the m of: year <br /> Company Address: Signature: <br /> Street Address City Zip Code <br /> o] All information submitted must be'com'complete, accurate, and legible <br /> r� <br /> DATE NAME OF BUSINESS OR (R)ADDRESS WHERE WORK WAS DONE GALLONS � NAIVE OF TREATMENT <br /> IT PUMPED PROPERTY OWNER PUMPED (G) ar--TRAp FACILITY <br /> lD PLEASE INCLUDE STREET $, DIRECTION, STREET NAME AND CITY C q{p er <br /> O ! A/ <br /> C. <br /> city <br /> c' <br /> city <br /> city <br /> cjty <br /> city <br /> Ci cr <br /> C- o <br /> z <br /> city <br /> zCm <br /> ciCityty <br /> City <br /> 0 <br /> O city <br /> fy <br /> L� <br /> city <br /> 2 <br /> CI <br /> a� <br /> rr� � <br /> Q city — <br /> city <br /> C > <br /> CU — <br /> EHD 42-04 <br /> i 10/4107 SEPTAGE CLEANERS REPORT °' <br />