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RECEIVED <br /> i f , SAN JOAQUIN COUNTY # <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by <br /> R ' ` JAN 0.7 2011 .600 East Main Street, Stockton,CA 95202-2708 the 12a'of each month <br /> a Q• , Telephone:(209)468-3420 Fax:(209)464-0138 Web:WWW.Sjg0V.org/ehd z #+ <br /> ENVIR ENTAL HEALTH '; D I1 <br /> PE T/ VI S , SEPTAGE CLE ER'S REPORT- <br /> Company <br /> EPORTCompany Name: Report fort oath o ! yeatY ! <br /> Company Address: <br /> ' Signatur <br /> Street AddressCity Zip Code <br /> All information submitted must be Complete. accurate, and legible f <br /> y, <br /> DATE NAME OF BUSINESS OR t (R) RESIDENTIAL <br /> PUMPED PROPERTY OWNER p ADDRESS WHERE WORK WAS DONE GALLONS NAME OF TREATMENT <br /> PLEASE FNCLUD <br /> PUMPED (G) CREASE TRAP FACILITY <br /> f�f ) .2 STREET N, DIRECTION, STREET NAME AN•D CITV7�., (C) CHEMICAL <br /> l� <br /> City <br /> t <br /> 'Ot .a~S L-�.�N'✓J <br /> City <br /> i <br /> /D <br /> city <br /> i <br /> cit i• i� 57$v�/ <br /> cit <br /> city65, <br /> cit l <br /> T cit <br /> Cay <br /> City <br /> 1.1-z <br /> City <br /> - <br /> r!✓e�� ' <br /> 4 cit <br /> FUD 42-04 <br /> - - Septic/Cesspool Report - <br />