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.� . . . -.—� . . -ti <br /> �. '. 4 SAN JOAQUIN COUNTY RECEMEA ENVIRONMENTAL HEALTH DEPARTMENT �� eturn this form b <br /> 600 East Main Street, Stockton,CA 95202-2708 �' ti�;� ZU� the 12th of each Month <br /> Telephone:(209)468-3420 Fax: (209)464-0138 Web:www.sjgov.orglV� Q <br /> SEPTAGE CLEA EWS REPORTPFR�N�� TH a. <br /> Company Name _ ` � Report for the nthRV s yea <br /> hh� i i <br /> Company Address: �C.� l Signature• <br /> Street Address City Zip Code ' 7M vii <br /> All information submitted must be complete, accurate, and legible 1 <br /> 6 (R) RESIDENTIAL <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS NAME OF TREATMENT ' <br /> PUMPED PROPERTY OWNER PLEASE IDIRECTION,+ PUMPED (G) CREASE TRAP i <br /> FACILITY <br /> _ NCLUDE STREET �, 'STREET NAME AND CITY � C CHEMICAL <br /> 5 i t Ci S L/ 1 .� <br /> itp f <br /> 1 ', L�' / id p�- Ci i ft <br /> r' !a /' Ci #-7 c7 / <br /> /4 760 ave <br /> Ci t ,j , r f) <br /> cy— ' sr ) n city ! 10 -44 y <br /> _ �iy " �� 71:i �: f e.✓ '�a��� 9� t'a' � Cit �T�'.(.� �`.x/3!3 '� � c,'��7` t <br /> �� % /' ' t� G" ✓0 '� / f-'n� Cit <br /> Cit <br /> /y./ rJ� city <br /> �/ � d li"�✓..Sr d ' S d `� �� �'�'e.Z�G...�S-� Git �S� .4 dl"!(9�_> e-- r <br /> City <br /> -,A 7779 / ,t <br /> 0. <br /> City <br /> �l1 // y' O Q 2 d�+/L cit <br /> ERD 42_94 a - { Septic/Cesspool Report <br />