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1 <br /> °o r SAN JOAQUIN COUNTY <br /> el ENVIRONMENTAL HEALTH DEPARTMENT Return this form by i <br /> 600 East Main Street, Stockton,CA 95202-2708t he 12th of each month <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd t <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: Report fort oath of yea <br /> // <br /> Company Address: /Q Pv Cel <br /> (}r <br /> 7J �, Sign `ture• <br /> street Address City Zip Code <br /> All information submitted must be complete, ace`urate, and legible I <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 /> : PLEASE INCLUDE STREET N, DIRECTION, STREET NAME AND CITY (C) CHEMICALPam } <br /> F <br /> f �T : 4� '; <br /> U&6Ce 1• (7l r .r C.�. cit !�� . <br /> U ! Cit — <br /> jt <br /> CLty <br /> � <br /> a z 7 �° ,p n ��I 4 <br /> s <br /> ;tv city <br /> CitC K-rOkj C4 2--9 'Q /W <br /> Ll <br /> & Ono citCX)l) 7f <br /> NMn <br /> T Pi ci �� CiK cr � j <br /> i' Cs 200 <br /> 14 <br /> Cit ' <br /> CI <br /> ty <br /> Cit <br /> city <br /> 1 <br /> cityr <br /> Cit ' <br /> Eft 42-04 j <br /> Septic/Cesspool Report <br /> } <br />