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' c�a % • '," SAN JOAQUIN COUNTY H M ��1/ 2 ENVIRONMENTAL HEALTH DEPAttTMENT Return this form by 600 East Main Street, Stockton,CA 95202-2708 LLrr p 2010 the - to of each mouth Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/e5g %r,-. �. _ SEPTAGE CLEANER'S REPORT ENVKuNMEN1 HSA TH �„ � rU PRMITISEN E Company Name: �— Report for the !nth of yeaQ�)16 Company Address: C �5 Signatur .� Street Address City Zip Code -All information submitted must be complete, ace'tirate, and legible DATE NAME OF BUSINESS ORADDRESS WHERE WORK WAS DONE 'GALLONS (R) RESUDENTIAL NAME OF TREATMENT PUMPED PROPERTY OWNER "PUMPED (G) GREASE TRAP FACILITY PLEASE INCLUDE STREET #, DIRECTION, STREET N-AMEiAND CITY 'r:. (C) CHEMICAL I n Ctty city � 71 Cit Cit Cit Ci;,. f �✓ '7,5 / I�s3' �'-✓ citY, cit Ci � ` e / / Ci city Ci' rte/ +�✓C,J� •- - �ZI d ✓ C�- I CiS I' �r� �!/ �� >✓ .�' - Cid ' ,. # .. ': Ct, E!�42-04 Septic/Cesspool Repoli .}