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�!H SAN JOA�QUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 600 East Main Street, Stockton, CA 95202-3029 12th of each month <br /> Telephone:(209)468-3420 Fax:(209) 464-0138 Web:www.sjgov.orglehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: 1)C,4 - �Z ��` IC s-C 7� L Report for the mo of: year <br /> Company Address: // - y 6c`X %� �� ���/ �/S Signature: <br /> Street Address city Zip code 1 11 <br /> 07 All information submitted must be'complete, accurate, and legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE IR) ItEs10EN11A1 <br /> f"7 GALLONS NAME OF TREATMENT <br /> © PUMPED PROPERTY OWNER PUMPED (G) GREASE TRAP FACILITY <br /> PLEASE INCLUDE STREET i, DIRECTION, STREET NAME AND CITY C CHEMICAL <br /> � ch <br /> C4 <br /> CAY <br /> city <br /> Cfty <br /> city <br /> M <br /> 0 <br /> l z <br /> ME <br /> CRYIS, <br /> I� <br /> city �+ <br /> O <br /> CV <br /> cidy <br /> t <br /> city 1_L <br /> city <br /> d <br /> C' <br /> lty <br /> [U ] <br /> I <br /> � EHD 42-04 SEPTAGE CIFA.NERS REPORT a� <br /> 1014107 aVi <br /> m C�— <br /> NNNVE <br />