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coy SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by <br /> j 600 East Main Street, Stockton,CA 95202-2708 <br /> the 12'h of each month <br /> oq �p Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> c, Z65 <br /> SEPTAGE C EANER'S REPORT <br /> Company Name: Report for th nth of: year�� <br /> Company Address: Signatur <br /> Street Address City ip Code <br /> All information submitted must be com tete, accurate, and legible <br /> DATE NAMEOF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAL NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED (G) GREASE TRAP FACILITY <br /> ty �n l PLEASE/i�NCLU6E STREET #, pIRECTION, STREET NAME AND CITV C) CHEMICAL <br /> r r � , <br /> Ci <br /> City <br /> l <br /> l City <br /> r 7r Z� 7 cit ��- <br /> Ci <br /> Ci <br /> Cit <br /> City <br /> Cit <br /> Cit <br /> city <br /> ri- <br /> City <br /> Cit <br /> city <br /> city <br /> O <br /> Gt <br /> Cit <br /> EHD 42-04 <br /> Septic/Cesspool Report <br />