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SAN JOAQUIN COUNTY <br /> y ENVIRONMENTAL HEALTH DEPARTMENT Return this form by <br /> 600 East Main Street, Stockton,CA 95202-2708 the 12`I'of each (month <br /> y Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.orglehd <br /> �'``Fa+za�P• ; SEPTAGE CLEANER'S REPORT <br /> Com any Name: Report for them nth of: yea <br /> p ` t <br /> Company Address: LC7 � t�[� r T "l-Sa�S Signature: fe <br /> Street Address City Zip Code <br /> lr <br /> All information submitted must be Com plete, a.ecurate, and legible- (R) RESIDENTIAL <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS G NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED ( ) CREASE TRAP FACILITY <br /> PLEASE hNCLUDE STREET H, DIRECTION, STREET NAME AND CITY C) CHEMICAL # <br /> o <br /> P Ci S 0 <br /> _z a ropit C k <br /> city <br /> k <br /> city <br /> �I <br /> Citv <br /> cit <br /> city <br /> City <br /> cit <br /> 1� <br /> P Ci f' <br /> Citv <br /> Cit <br /> 1 <br /> city <br /> city <br /> rt <br /> i city <br /> Cit <br /> Septic/Cesspool Report <br /> EFID 42-04 <br />