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SAN JOAQUIN"COUNTY rte^ I <br /> ENVIRONMENTAL HEALTH DEPARTMENT ;. <br /> Return this form by <br /> t Lora f� 600 East Main Street, Stockton,CA 95202-270$ , , the 12�'of each month <br /> " Aij� Tel phone:(209)468-3420 Fax:(209)464-0138 Web:www.s ov.or ehd <br /> l=pRpjHEAJH <br /> ENTER <br /> AC SEPTAGE CLEANE 'S REPORT <br /> �^^ <br /> v l�1 i 1 <br /> Company Name: 1" � Report for the oath of: yeaQab Y F <br /> Company Address: Signature.- <br /> Street Address city Zip Code. <br /> j. <br /> All information submitted must be complete, accurate, and legible ` <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE t GALLONS (R) RESIDENTIAL NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER : i PUMPED (G) GREASE TRAP FACILITY <br /> PLEASE INCLUDE STREET !F, DIRECTION, STREET NAME AND CITY 4 (C) CHEMICAL ' <br /> City <br /> Imo ' Cit c abp <br /> 3 -2 <br /> i City ✓�' �d�� <br /> 6 s <br /> d Buc�sT �,v8.i Ci �c <br /> Cit / <br /> Citycill <br /> m <br /> Ci <br /> r/ City <br /> City <br /> �614t. <br /> � City <br /> cit 14� City <br /> ✓ it <br /> yf i w. j <br /> Cit k <br /> EHD 42.04 }. <, <br /> -D Septi&Cesspool Report <br />