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L <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 600 East Main Street, Stockton, CA 95202-3b29 12th of each month <br /> IL Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: cs Report for the m n of: ye r o 3 <br /> Company Address: - �S l ��3 Signature: <br /> ?'�E <br /> Stree Address City .Tip Code <br /> OD All Information submitted must be*complete, accurate, and legible <br /> 1-1 DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS IR1 NAME OF TREATMENT <br /> CD PUMPED PUMPED PROPERTY OWNER (G) GREASE TRAP <br /> PLEASE INCLUDE STREET i, DIRECTION, STREET NAME AND CITY C CHp�� FACILITY <br /> rt <br /> O AVdPlel > <br /> f— <br /> cfty <br /> G <br /> Citv <br /> ity <br /> CRY <br /> city <br /> city m <br /> C-1 <br /> City <br /> 0 <br /> city <br /> 2 <br /> c.ty <br /> ", <br /> city _— <br /> m <br /> C o <br /> E C' <br /> OCE <br /> m <br /> LL city <br /> Q <br /> Lf l <br /> city <br /> cityi <br /> ro city <br /> n� <br /> m � <br /> EHD 42-Q4 SEPTAGE CLEANERS REPORT <br /> i 1014107 <br /> a> <br /> J � <br /> E ■■ <br />