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SAN JOAQUIN COUNTY <br /> , :..: <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:(208)464-0138 Web.v+rww.sjgo�€� lehd <br /> C-, <br /> SEPTAGE CLEANER'S REPORT E,N74 RE <br /> Company Name: • Report for the month of.. year <br /> Company Address: Signature: <br /> r� Slreel Address City Zip Gods <br /> O <br /> o All information submitted must be com ]eta accuFat0 and le able <br /> DATE HAMEOF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS {R) RESIUKHAL NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED {G1 GREABETRAP FACILITY <br /> PLEASE rNC-LIJDE STREET 6, DIRECTION, a1REE1 NAME AMC CITY C CHEMICAL <br /> city <br /> city <br /> city <br /> Gi <br /> Gi <br /> city <br /> Gety <br /> ity <br /> Ci <br /> Gity <br /> Gi <br /> citw <br /> Crity <br /> city <br /> i Q <br /> ily <br /> Lr, <br /> Ity <br /> rn <br /> rn Gill? <br />: o <br /> � ity <br /> m <br /> city <br /> cr+ <br /> 7 <br /> 0 <br /> z EHO42-99 SEPTAGEOLEANFRS REPORT <br /> WOW <br />