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SAN JOAQUIN COUNTY <br /> ( ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> A�.0 s ZO�3 600 East Main Street, Stockton, CA 95202-3029 le of each month <br /> �,¢ ( Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> SEPTAGE CLEANERS REPORT <br /> Company Name: /YJ� Report for the mo th of: ye <br /> Company Address• Signature: <br /> 'Street Address City Zip Coda <br /> Cu All Information submitted must be'com lets, accurate, and legible <br /> F) <br /> o DATE NAME OF BUSINESS OR ADDRESS WHERE'WORK WAS DONE GALLONS « Res'E'nm NAME OF TREATMENT <br /> CD PUMPED PROPERTY OWNER PUMPED (G) GREASE TRAP FACILITY <br /> T / PLEASE INCLUDE STREET i, DIRECTION, STREET NAME AND CITY C CHEMAL <br /> UJ 1 <br /> u C• <br /> city <br /> city <br /> city <br /> CRY <br /> city <br /> city <br /> O <br /> cityc" <br /> m <br /> city <br /> 0 <br /> z <br /> y, C. <br /> _� Q <br /> CRY <br /> C-4 <br /> CRY <br /> m <br /> Ac O <br /> CV <br /> CRY <br /> O <br /> I city <br /> U0 <br /> 2 <br /> u� <br /> cityQ <br /> r� <br /> city <br /> City <br /> LD <br /> 0i — <br /> r` E1 D 42-04 SEPTAGE CLEANERS REPORT <br /> i 10/4/07 <br /> (R <br /> 1 ' <br />