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-o SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by <br /> ` 600 East Main Street, Stockton,CA 95202-2708 the 12"of each month <br /> P' Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sigov.org/ehd <br /> aLrFORa <br /> SEPTA E CLEANER'S REPORT <br /> Company Name: Report for the th of year <br /> Company Address: Signature: <br /> Street Address ty Zip Code <br /> All information 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 /> PLEASEINCLUDE STREET #, DIRECTION, STREET NAME AND CITY C) CHEMICAL <br /> city's ric <br /> 0 C. <br /> y, <br /> '`g4 e ti 7 varro city J,` AIA T5 <br /> e + Cep c= 04 <br /> ® cit / r,4 Z o <br /> ci ° <br /> ci <br /> Cit <br /> city <br /> City <br /> City <br /> city <br /> City <br /> city <br /> City <br /> city <br /> cit <br /> FIiD42 04 Septic/Cesspool Report <br />