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°oG SAN JOAQUIN COUNTY <br /> z ENVIRONMENTAL.HEALTH 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 /> P <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: Rgport for the month of: yeah <br /> Company Address: S Sinature• <br /> Street Address City Zip Code <br /> All information submitted must be complete, accurate, and legible t <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 #, DIRECTION, STREET NAME AND CITY CnEMICAL <br /> i U ST <br /> (' (� IA rd city <br /> �o cCity S <br /> k 7r b fQ Ci iC <br /> 2 O Ex 6 V. ci ' `2— r <br /> Ci <br /> Ci R <br /> `3oCil , <br /> ci!)SLO V <br /> Cil <br /> city <br /> city <br /> city <br /> city <br /> Cit <br /> city <br /> Cit <br /> Cit <br /> Ciry <br /> i <br /> Cit <br /> EHD 42-04 <br /> —� Septic/Cesspool Report <br />