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SAN JOAQUIN COUNTY <br /> �=o ENVIRONMENTAL HEALTH DEPARTMENT / eturn this form by <br /> 600 East Main Street, Stockton,CA 95202-2708 ""`^ th <br /> ' of each month <br /> ' <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/eF►d a -� <br /> SEPTAGR CLEANE 'S REPORT <br /> Company Name: _ Report for the nth yea I <br /> Company Address: A Signature• <br /> Street Address ' City Zip Code <br /> All information submitted must be com lete, accurate, and legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAL TREATMENT <br /> TR <br /> NAME OF i <br /> PUMPED PROPERTY OWNER t PUMPED (113) GREASE TRAP OF TR FACILITY <br /> l J PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY y. C) CHEMICAL <br /> ;V ' m/ 'e City <br /> �� ,P <br /> City ul/ <br /> Cityrr� s i� <br /> '6 . •✓ �U cit <br /> city <br /> ' CL- <br /> City <br /> Ci <br /> Cit 9� -7d <br /> � � r <br /> �� d gyp' s r -y 7� Cityj G <br /> � f J1 <br /> _City 1114— <br /> ✓ Z"�' r. �t�� Cit <br /> City <br /> Cit G�DU i� <br /> r Ci J <br /> rrte�- T X21��i zz� ' cit �i <br /> Cir y <br /> EFIll 42-04 i Septic/Cesspool Repori <br />