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aur SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 600 East Main Street, Stockton, CA 95202-3029 120 of each month <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> ' b SEPTAGE CLEANER'S REPORT <br /> Company Name: g,1,7� , <br /> Report for the mo th of: year <br /> Company Address: 2�)6yV� Signature: <br /> Street Address coy Zip Code <br /> co All information submitted must be complete, accurate, and legible <br /> nAL <br /> r DATE NAME OF BUSINESS OR ADDRESS WHERE WORKWAS DONE (R) GREASE <br /> TRA <br /> GALLONS NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED (G) eREasE TRAP FACILITY <br /> Ul <br /> PLEASE INCLUDE STREET S. DIRECTION, STREET HANE AND CITY C CHEHICAL <br /> 0 c <br /> C' <br /> C' <br /> city <br /> C' <br /> C' <br /> citv <br /> CRY <br /> Cfty <br /> Cr <br /> 0 <br /> j <br /> cftyz <br /> t d <br /> city <br /> 'C <br /> O <br /> CV <br /> O <br /> cfty <br /> city <br /> Q1 C E� <br /> F— <br /> CU <br /> i <br /> EHD 42-04 SEPTAGE CLEANERS REPORT — <br /> V <br /> ��/ 10/4107 a> <br /> LL <br /> kT <br /> I. I.■ti1 111 E <br /> Ii1 I. 1. E 0 <br />