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oy RECENED SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form`1 by <br /> UCT 0 5 4u� 600 East Main Street, Stockton,CA 95202-2708 the 12`6 of each month <br /> ENVI Nivir IV f HEALTH Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> cA�f F�Ra\4 1 SERVICE _ SEPTAGE SANER'y5 REPORT <br /> Company Name: 14.4 1 VReport for the nth of l <br /> p >�yeaz� <br /> Company Address: <br /> 9<0 <br /> Signature- <br /> Street Address City Zip Code <br /> All information submitted must be complete, accurate, and legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RESmENTIAL NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED (G) GREASE TRAP FACILITY <br /> �� PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY (C) CHEMICAL <br /> L�� � i✓ City <br /> 3530 city 41-11-7 �7 <br /> City <br /> City <br /> Cit <br /> Cit <br /> City <br /> Cit <br /> Ciry <br /> Ci <br /> City <br /> City <br /> Cit <br /> City <br /> Cit <br /> City <br /> 1vl <br /> 3 Clt <br /> r <br /> EHD 42-04 <br /> Septic/Cesspool Report <br /> i <br />