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' co SAN JOAQUIN COUNTY <br /> _Y G <br /> ENVIRONMENTAL 1 EALTH DEPARTMENT Return this form by � <br /> �fLa s 600 East Main Street, Stockton,CA 95202-2708 the 12te of each month <br /> ' Telephone:(209)468-3420 Fax:(209)464-0138 Web:www_sjgov.orglehd <br /> 'S.EPTAGE CLEANER'S REPORT { <br /> Company Name: Rep rt for the mo th of: year ! <br /> Company Address: (�a� �. 'C�lJl�l O;n (� ]� q0] Sign tore: / s <br /> Street Address City Zip Code <br /> i ' <br /> All information submitted must be complete, accurate, and legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE i GALLONS (R) RESIDENTIAL NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER I TR <br /> PUMPED (G) GREASE AP FACILITY <br /> PLEASE INCLUDE STREET *, DIRECTION, STREET NAME AND CITY C CHEMICAL <br /> city <br /> City, J ✓ -IS4 Alf— <br /> City t <br /> _ 4 <br /> D-?✓-L�� c�%O.ah(,r bn � /?5 ' r � /.°�.� Ci <br /> 1� ✓ l � A �' y� i✓ ci r � X64 G <br /> -o Q ci <br /> iL city <br /> Cit <br /> Cityti <br /> City <br /> i <br /> City <br /> 1 <br /> City <br /> city <br /> City +:. <br /> Cit <br /> City <br /> t' <br /> Cityi <br /> �. k <br /> Cit <br /> EHID 42-04 Septic/Cesspool Report <br />