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SAN JOAQUIN(AUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by <br /> W <br /> 600 East Main Street, Stockton,CA 95202-2708 the 121'of each month <br /> Telephone:(209)468-3420 Far:(209)464-0138 Web:www.sjgov.org/ehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: �l �1 Report for the month of year <br /> Company Address: a �S Sig�ature• <br /> Street Address City Zip Code <br /> All information submitted must be Com fete, accurate, and legible <br /> DATE NAME OF BUSINESS OR (R) RESIDENTIAL <br /> PUMPED PROPERTY OWNER ADDRESS WHERE WORK WAS DONE GALLONS G NAME OF TREATMENT <br /> PUMPED { ) GREASE TRAP FACILITY <br /> PLEASE INCLUDE STREET p, DIRECTION, STREET NAME AND CITY (C) CHEMICAL <br /> jut A0240 Y A <br /> CI <br /> 70 <br /> Ci L" <br /> ,sy c; WO <br /> �" <br /> Cit 4 <br /> R a S c;t K C <br /> Ci 2500 <br /> 3 <br /> Ci , q27�E 7-A <br /> c;t � <br /> Ci <br /> Ci <br /> c;t 1 <br /> c; <br /> Cit <br /> City <br /> c;ty <br /> Ci <br /> cit <br /> c; <br /> CF <br /> f <br /> Clt <br /> 1 <br /> EI3D 42-04 <br /> Septic/Cesspool Report <br />