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SAN JOAQUIN COUNTY <br /> .A ENVIRONMENTAL HEALTH DEPARTMENT Return this form by <br /> t 600 East Main Street, Stockton,CA 95202-2708 % th <br /> y the 12 of each month <br /> c I Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov. ehd'w� <br /> r>=o <br /> ` SEPTAGE CLEANER'S REPORT <br /> Company Name: tJcal!5�� Report for the th of. ear <br /> a � y Q. tt <br /> Company Address: • Signature: .--: <br /> Street Address City Zip Code ' <br /> t <br /> All information,fsubmitted must be complete, accurate, and legible ,y <br /> I i <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) REsIDENTuL NAME OF TREATMENT <br />' <br /> PUMPED. PROPERTY OWNER PLEASE CNCLUDE PUMPED (G) GREASE TRAP FACILITY <br /> STREET #> DIRECTION, STREET NAME AND CITY (C) CHEMICAL <br /> (J c <br /> City <br /> cit <br /> City <br /> L- -'� city � <br /> X) cit <br /> 6 ,. . _, Cit <br /> a-/ -jv L Sy -1 �.✓ City m ,,t/ <br /> Ci <br /> M 61Z�^ � 4�✓� Lr> � �c1 ci �-f���-�/ ZSO U � Sf "'�[� <br /> ci <br /> ty <br /> i ✓ U ciiy <br /> ; <br /> City <br /> ci >✓ t <br /> cit d <br /> EHD 42.04 <br /> Septic/Cesspool Report J+ <br />