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00 SAN JOAQUIN COUNTY �3 <br /> i ENVIRONMENTAL HEALTH DEPARTMENT r: Return this form by <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.orglehd e <br /> • Vic.. ,..- . .P �,- i <br /> �GlFOR�` ;} SEPTAGE CLEANER'S REPORT <br /> Company Name: (al ,r Re for the nth of: yca �o <br /> Company Address: I l " � <br /> e•/ Sigtur <br /> Street <br /> Address —city Zip Cade <br /> All information submitted must be complete! accurate, and legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS �) RESIDENTIAL NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER I is PUMPED (G) GREASE TRAP FACILITY . <br /> PLEASE IINNC✓LLUDE STREET k, DIRECTION, STREET NAME AND CITY41: (C) CHEMICAL <br /> ci <br /> .fes City <br /> / ✓rJ 7�P / J/CJ <br /> cityl <br /> g. <br /> citycity <br /> x; is <br /> C;t7�r6 n r3Q. <br /> l �,- r � city <br /> �. <br /> � � <br /> cit � �. <br /> city e, 6j tvj <br /> r f a cidIle <br /> ' <br /> city <br /> } <br /> Cit } <br /> Cit # <br /> Cit <br /> } Ci ; <br /> K <br /> City 1 <br /> City <br /> 1' <br /> E a2-aa � <br /> -..•----. �, SeptidCesspool Report <br />