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ca � SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT f' Return this form by <br /> 600 East Main Street, Stockton,CA 95202-2708 . the 12`h of each month <br /> ' t ' Telephone:(209)468-3420 Fax:(209)464-0138 Web:ww-w.sjgov.org/ehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: 0 • Reprtfor the oath of: yea r <br /> s <br /> Company Address: �S Signature: <br /> Street Address City Zip Code i <br /> F 9 <br /> All information submitted must be complete, accurate, and legible k <br /> {R) RESIDENTIAL <br /> DATE NAME OF BUSINESS OR, ADDRESS WHERE WORK WAS DONE GALLONS NAME OF TREATMENT ' <br /> 7<, (G) GREASE TRAP <br /> PUMPED PROPERTY OWNER PLEASE I`N'C L U D E STREET #, DIRECTION, STREET NAME AND C I T Y• PUMPED C CHEMICAL FACILITY <br /> C'J �- <br /> f Citv , <br /> I v- <br /> w Ci .- 1 sow 1 <br /> S <br /> 9 Ci o W-5-0- 0 /U. � <br /> C !V. P4QJ f I CityC+r Q <br /> -d� D ✓' 9 <br /> city <br /> cit z DD G <br /> Q ci © <br /> 4 Q -�Aefj 0 City5z erA re A.1 r ! YV. <br /> _ i Cr 0 CirA, 2 SOQ <br /> - r, t Ci k7A A j C A. <br /> �1. p <br /> e t Ci 7` <br /> ILYA Gcboml city <br /> ci ► <br /> 7 <br /> IU V • 0 1 Clt ✓ �� 3 <br /> I. <br /> EHD 42-0a <br /> _ --_ � �1, Sep[idCesspool3tepaR <br />