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CQ SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by <br /> ` 600 East Main Street, Stockton,CA 95202-2708 the 12'h of each month <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> Wjx6 <br /> a <br /> { SEPTAGE CLEANER'S REPORT <br /> C—V 60Company Name: A��K` Report for the mouth of: yeal�� <br /> Company Address: { eF <br /> Signature: <br /> Street Address Gity Zip Code <br /> All information submitted most be complete, accurate, and legible <br /> DATE NAME OF BUSINESS OR (R) RESIDENTIAL <br /> ADDRESS WHERE WORK WAS DONE GALLONS NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED (G) GREASE TRAP FACILITY <br /> PLEASEIINCLUDE STREET) #, DIRECTION, STREET NAME AND CITY C CHEMICAL <br /> J PrI114 C.1.10 City L 7n p , G L <br /> C 0 <br /> city- <br /> �7 1—le, Cit <br /> city <br /> City <br /> a <br /> city <br /> Cit <br /> city <br /> Cit <br /> cit <br /> city <br /> Cit <br /> City <br /> cit <br /> ti <br /> city <br /> cit <br /> city <br /> city <br /> Cit <br /> EHD 42-04 <br /> --------- Septic/Cesspool Report <br />