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r NAN JOA UIN COUNTY �r D MEWED <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by <br /> �< 600 East Main Street, Stockton,CA 95202-2708 B 0 2 2010 the 12th of each month s <br /> Telephone:(209}468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ <br /> k <br /> SEPTAGE CLEANER'S REPORT ENViRONMEN H��-TN <br /> PERMIT/SERVICES <br /> Company Name: Report for the th of: 1V� U year&u6 <br /> r y <br /> Company Address: I Signature: - <br /> `-Street Address City Zip Code I R <br /> ;. A11 information submitted must be com fete,' accurate, and legible <br /> r 4 <br /> ENTERED <br /> l <br /> DA'I'S NAME OF BUSINESS OR l /ADDRESS WHERE WORK WAS DONE `- GALLONS (R) RESIDENTIAL NAME OF TREATMENT ; <br /> PUMPED PROPERTY OWNER PUMPED (G) GREASE TRAP FACILITY <br /> PLEASE,. INCLUDE STREET p, DiRECTfO,N, STREET NA,wlE AND CITY (C) CHEMICAL 5 <br /> city sir O <br /> city <br /> 1 —'��/ �`�JG[i!-7✓,� �f/ �/—'lf/� � ' city. ��Z-�/�(/ fi �s� ✓r� v � �� <br /> City <br /> city <br /> fi <br /> city <br /> i v <br />' -/ V j f/, R • Cit <br /> t � <br /> d lei r? t ,r?i -Palo of �z c Y?C ci a L} 5.' .f 14! <br /> 3 <br /> Cit <br /> ` I <br /> I: ?�r✓ • l�i7 L> City 9 ! ��GY✓ j <br /> Ci <br /> - d- E 2XI V. TIL <br /> Ci c <br /> -oo Io +sr aa �� WCRY5 kle rAl. 114 �126V 9. 4. <br /> City <br /> I� $ )e C City 5-00 !s / <br /> I / <br /> t r� <br /> t Ci s <br /> • -SACS# c� city -, fro <br /> EHD 42-04 �`� Septic/Cesspool Report <br />