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-. —: I <br /> SAN JOAQUIN COUNTY <br /> 02 y ENVIRONMENTAL HEALTH RECEIVE DEPARTMENT eturn this form b <br /> 600 East Main Street, Stockton,CA 95202-2708 tl, y <br /> / the 12 of each month <br /> s,Te ''honer 2 9)468-3420 Fax:(209)464-0138 Web:www.Sjgov.org/ehd DEC 0 2 2010 <br /> t11 SEPTAGE CLEANER'S REPORT,,' <br /> !' :�� F. <br /> ENVIRONMENT <br /> Company Name: Report.for,thF yea +- <br /> Company Address: ' 1,� � {' Signature: <br /> Street Address City Zip Code 1 <br /> All information submitted must be complete, ac(urate, and J eg i b I c <br /> 1 <br /> DATE NAME OF BUSINESS OR <br /> ADDRESS WHERE WORK WAS DONE R�GALLONS � � REsmENr1AL „a NAME.OF TREATMENT <br /> t PUMPED PROPERTY OWNER PUMPED (G) GREASE TRAP `- <br /> PLEASE IN- LUDE STREET 0, DIRECTION, STREET NAME AND CITY C7 CHEMICAL FACILITY <br /> cit <br /> Cit <br /> �.. City <br /> D U <br /> city 2 <br /> city � <br /> City f <br /> cit <br /> Yf �/ <br /> City <br /> v � G <br /> _Ciricii <br /> - �r <br /> city <br /> ,t <br /> f l at z, / <br /> r--�za - - <br /> —City <br /> i <br /> city <br /> n_y <br /> fly f Ci <br /> City P �!� J' it <br /> EI ID 42-04 l Septic/Cesspoot Report <br />