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r °? SAN JOAQUIN COUNTY <br /> < ENVIRONMENTAL HEALTH DEPAR'T'MENT � Return this form by <br /> y 600 East Main Street, Stockton,CA 95202-2708 the 12�'of each month <br /> �q�rFo ��4 Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov. - <br /> SEPTAGE CLEANER' REPORT <br /> Company Name: t <br /> ' <br /> Company Address: Report f05 n f• yea <br /> /Sign <br /> - <br /> e ` <br /> trees Address '• City - Zip Code <br /> All information submitted must be om tete, acGJDrate, and legible P RV�Ci <br /> cs <br /> ATF. NAME OF BUSINESS OR <br /> PUMPED PROPERTY OWNER f�; ADDRESS WHERE WORK WAS DONE (R) RESIDENTIAL <br /> `` GALLONS NAME FA TREATMENT <br /> PLEASE INCLUDE STREET 0, DIRECTION, STREET NAME AND CITY PUMPED �G) GREASE TRAP FACILITY <br /> (C) CHEMICAL <br /> city <br /> / � DcIO' �� rt/ � •p�} moi' ,�/ <br /> /% �f�/ Gd o.✓ �- city S'%_���✓ D�� <br /> TJr <br /> s <br /> 7 cit <br /> Citi —i'Ir�/ <br /> �r// ����'0 c—'ir`P/il✓1J� / Cit <br /> city <br /> ?v City <br /> City <br /> Cl S+ J F �/✓ � _ <br /> C. <br /> �7lr�i Cit city <br /> City <br /> City 5 <br /> Ci <br /> Cir <br /> EBD 42-04 <br /> t Septic/Cesspool Report <br /> I4 <br />