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!I' SAN JOAQUIN COUNTY <br /> "c ENVIRONMENTAL HEALTH DEPARTMENT4` Return this form by r . 600 East Main Street, Stockton, CA 95202-2708 <br /> y 4; the 12te of each month <br /> <. < P g/ja <br /> Tele hone:(209}468-3420 Fax:(209)464-0138 Web:www.slg <br /> ov.Ir , <br /> SEPTAGE CLEANER'S REPORT ENVIRONMENT MEAL <br /> pJRMITJSERVICE <br /> Report or the th of: yeaa209 <br /> ' <br /> Company Name: � k` V5 Signature• � <br /> an Address: city zip cone <br /> companStreet A dress �� <br /> accurate, and legible <br /> All information submitted must be c o m tete, ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAL NAME OF TREATMENT <br /> BUSINESS OR <br /> DATE PUMPED {G} GREASE TRAP <br /> PROPERTY OWNER PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY (C CHEiv!lCAL FACILITY <br /> NAME OF <br /> PUMPED 1. <br /> vZkT&L <br /> CAci , 75 <br /> Q� <br /> Cit ©o <br /> cont, '14ciryN. J <br /> �! �� ci 5 5` 0 C S' <br /> L{ Q r <br /> . <br /> uJclt t ESQ© <br /> Q Q <br /> ro/.. Ci S' j i <br /> d9 d m <br /> Dq ci C , <br /> �? octCity k <br /> -o5 0 , <br /> Ci <br /> L' <br /> Citv, C a 1 <br /> 16 <br /> city 5T2 1A �37 A <br /> I <br /> �fl Septic/Cesspool Report <br />