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SAN JOAQUIN COUNTY <br /> u w, ENVIRONMENTAL HEALTH DEPARTMENT [Return this for600 East Main Street, Stockton, CA 95202-30292ei of each mo by the <br /> Telephone: (209)468-3420 Fax: (209)464-0138 Web:wwwsjgov_ org/ehd nth <br /> a = SEPTAGE CLEANER'S REPORT <br /> s � — Report for the M <br /> 95 Signature: Year�_� <br /> Company Name: X y Q'( Lp Code <br /> Company Address: StreaiAddrecm <br /> ss <br /> ible <br /> must be teteiR) <br /> LO All information submitted , actor DUREGALLONS <br /> SS ygL{ERE WORK WAS DONE REswENTIALPUMPED (G) GREASE TRAP NAME OF TREATMENT <br /> ti DATE NAME OF BUSINESS OR DIRECTION, STREET NAME AND CITY - G CN&dICAL FACILITY <br /> CD PUMPED PROPERTY OWNER PLEASE INCLUDE STREET s, <br /> FI � c. <br /> V <br /> OIcity <br /> c <br /> O' <br /> C' <br /> city P °NMENTA HFALTt, <br /> c <br /> c <br /> G <br /> cay <br /> C- <br /> City <br /> cay P °NMENTA H <br /> C <br /> FS <br /> city <br /> F <br /> city <br /> 0 <br /> ry O <br /> LL <br /> a C <br /> � I <br /> m CI <br /> N ISEPTAGE CLEANERS REPORT <br /> .-1 <br /> 0 EA <br /> N <br /> EHD 42-04 <br /> JOW07 <br />