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I SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form <br /> Y <br /> 600 East Main Street, Stockton,CA 95202-2708 the 12'of each month <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> SEPTAGE CLEANE 'S REPORT <br /> dmpany Name: C Re oil for the nth of:Qea 1 <br /> P Y <br /> e pang Address: Q C)(D Signature: <br /> Street Address City Zip Code <br /> A information submitted must be complete, accurate, and legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAL NAME OF TREATMENT <br /> PUMPED PROPERTY OWNERPUMPED (G) GREASE TRAP FACILITY <br /> PLE[A�S�EJ�FN7L6DE STREET IF, DIRECTION, STREET NAME AND CITY (C) CHEMICAL <br /> / <br /> city <br /> y� <br /> City <br /> o r� t z� City ✓ �t� G �� <br /> { <br /> Cit <br /> Cit <br /> City <br /> city <br /> Cit <br /> city <br /> City <br /> City <br /> Ci <br /> ty4iF <br /> city <br /> I <br /> City <br /> [ cit <br /> { <br /> city <br /> 1 <br /> Cit <br /> i <br /> city <br /> City <br /> Cir <br /> EHD 42-04 <br /> Septic/Cesspool Report <br />