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i SAN JOAQUIN COUNTY ' <br /> ' ENVIRONMENTAL HEALTH DEPARTMENT ' Return this <br /> y MAY � 7 2008 �; 600 East Main Street, Stockton, CA 95202-2708 � to farm by <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgo'v, r the 12 of each month <br /> ENVIRONMENT HEALTH a' ENTERED_ <br /> PER T/S>=RVIC <br /> SEPTAGE CLEANER'S REPORT � 1 i <br /> Company Name: r .. _---- I <br /> -- 1 � <br /> Company Address: <br /> d. r Report for the th of: yea <br /> Street Address i+ Signature' <br /> City Zip Code <br /> All information submitted must be Complete. accurate, and le ible <br /> i; ; <br /> DATE NAME OF BUSINESS OR r <br /> PUMPED PROPERTY OWNER ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAL NAME OF TREATMENT <br /> PLEASE INCLUDE STREET 4, DIRECTION, STREET NAME AND CITY PUMPED (G) GREASE TRAP FACILITY <br /> CQ CHEMICAL <br /> �I <br /> 4: Ci l` C <br /> I' <br /> Ci <br /> �em- <br /> eq, c;t . 2 <br /> - Cit <br /> r a <br /> City <br /> city <br /> City fj7­njfk7v10(_) <br /> 9q ` ci <br /> 9. <br /> Roll" 11 <br /> t `f ;7. a <br /> Ci � ' �j <br /> Cit 192 <br /> CA J �2 ! <br /> i <br /> cit � ���✓ <br /> null <br /> S t ,I <br /> Ci <br /> 00 <br /> c, r-Ot 1, <br /> 574-7 Al <br /> cit p ti i <br /> Cit S^r Q Q <br /> EHD 4Z-04 <br /> Septic/Cesspool Repoli <br />