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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTm DEPARTMENT Return this form by <br /> 600 East Main Street, Stockton,CA 95202-2708 the 12th of each month <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov:org/ehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: Z�24— Report for the nWnth of: ye ]— <br /> y i <br /> Company Address: Signature: . <br /> Street Address City Zip Code <br /> All information submitted must be complete, accurate, and legible ; <br /> BATE 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 INCLUAE STREET N, DIRECTION, STREET NAME AND CIT (C) CHEMICAL <br /> It Z CiO <br /> G Ci <br /> r-- <br /> 1S city r C� 1 <br /> CityXf-jL. <br /> f <br /> -O e 3 D city5ro G G 7 <br /> 99 <br /> Ci <br /> q122 <br /> —DS Ci <br /> 1 <br /> 1 Cit <br /> iAlkP Ci <br /> I` l 9 <br /> P Cit <br /> 1 Ci 0 <br /> i <br /> MAI �IkjluCi , <br /> t <br /> r Ci 7 <br /> City <br /> t.. <br /> City <br /> Ci[ ; <br /> City ENT'D O c ; <br /> v <br /> city <br /> f I } <br /> city <br /> Cl[ <br /> EHD 42-04 <br /> _--- Septic/CesspoalRepoR <br /> v <br />