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eG SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by <br /> j 600 East Main Street, Stockton,CA 95202-2708 the 12'b of each month <br /> Telephone:(209)468-3420 Fax.(209)464-0138 Weft:www.sjgov.org/ehd <br /> C' \P <br /> R�rFOR <br /> SEPTAGECLEANER'S REPORT } <br /> Company Name: i0oue• Report for the m th of: ye'00� <br /> Company Address: 5� Signature: <br /> Street Address City 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 H, DIRECTION, STREET NAME AND CITY /j (C) CHEMICAL <br /> Ci ° CA 00 fk <br /> Cit / T <br /> 2 ,�. <br /> 7ci 5©0 � <br /> I ' i <br /> . <br /> U 7, C <br /> +' / f Cit 2TM '57 <br /> '! ` f, t7ci i7[3c "T <br /> ity <br /> Ci <br /> Cit <br /> City <br /> Cit <br /> city <br /> city <br /> Ci[ <br /> EI 42-04 <br /> Septic/Cesspool Report <br />