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c°c SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by <br /> 600 East Main Street, Stockton,CA 95202-2708 the 12th of each month <br /> C'• •p <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Na % qReport for the month of. year <br /> Company Address: a5at Signature: <br /> Street Address City Zip Code <br /> All in 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 OWNER PUMPED (G) GREASE TRAP FACILITY <br /> PLEASE INCLUDE STREET W, bIRECTION, STREET NAME AND CITY (C) CHEMICAL <br /> 2 <br /> C/-YO , <br /> Cily <br /> Its- 4 � <br /> city <br /> M n <br /> Cit <br /> City <br /> Oo city <br /> Cit <br /> city <br /> city <br /> city <br /> City <br /> city <br /> Cit <br /> City <br /> Ci <br /> City <br /> EHD 42-04 <br /> Septic/Cesspool Report <br />