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RECEIVE® <br /> q 12 <br /> SAN JQAQUIN COUNTY ; <br /> Ll �, ENVIRONMENTAL HEALTH DEPARTMENT Return this form ti the <br /> E00 East Main Street, Stockton, CA 95202-3029 ENTALHFhL� 12'"of each month <br /> 5 Telephone:(209)468-3420 Fax:(209)464-0136 Web:www.sj$N P�j$ERVICES <br /> /SEPTAGE CLEANER'S REPORT <br /> Company Name: J/ [// /v� [�//d/G_�Ll �� Report for the nth year <br /> Company Address: Signature: <br /> Smmt Address City Zip code <br /> All Information submitted must be Complete, accurate, and legible <br /> m DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) REsw0 rLu NAME OF TREATMENT <br /> r PUMPED PROPERTY OWNER PUMPED IG) CREASE TRAP FACILITY <br /> m - <br /> 4- <br /> PLEASE INCLDCE STREET {, DIRECTION, STREET NAME ANO CITY - C CHEMICAL <br /> e � <br /> v , <br /> Cry <br /> 0 <br /> City <br /> CRY <br /> C' <br /> C' <br /> City <br /> city <br /> city <br /> cfty <br /> C1111 <br /> city <br /> C' <br /> rty <br /> CRY <br /> C' <br /> city <br /> F <br /> city <br /> 11 <br /> CE CNY <br /> N <br /> N <br /> C' <br /> N <br /> m <br /> C' <br /> N <br /> ti <br /> m <br /> Cu EHO42-04 SEPTAGE CLEAVERS REPORT <br /> 10W <br /> ' to/am <br /> In <br /> d <br /> C[ <br />