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;, ��� SAN JOAQUIN COUNTY <br /> I to lam: 0?0 , <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 7 . q i <br /> F q d<) 1868 East Hazelton Avenue , Stockton , CA 95205 -6232 12th of each month <br /> Telephone : 209 468-3420 Fax: 209 464- 0138 Web : www . sjgov , orglehd <br /> •�jFQ 'v <br /> SEPTAGE CLEANER' S REPORT <br /> Company Name : � � Report for the onth of : year D <br /> y 0 0 <br /> � �- e a <br /> Company Address : a `l (JPC" � k�® �� � �` . Pc O nee `��1� � Signature : <br /> Street Address City Zip Code <br /> All information submitted must be cam lete accurate , and legible <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 4 , DIRECTION , STREET NAME AND CITY / C CHEMICAL <br /> �t /� <br /> 7 r � C7r /n �' � 10l ( 0 0 /vr � l Cit C.�j U / �00 ge5 s 1 � (� <br /> 7 ` '4r^ d yr J () /Ur H w 1 city 67<f ry v /!-S � u-j T <br /> 7 " o r b � � P � � / e if • C Cit ` eg � R w T <br /> 17 - � S �rbm � )nq P to4' o N � w � Cit c4o4lc ) 3& 0c ' <br /> ? - a 5 �. � � � � />tl�� �' � a � ► ra GIS cityLoComm, r e� � � ? <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> City <br /> City <br /> Cit <br /> City <br /> - City <br /> Cit <br /> City <br /> Cit <br /> Cit <br /> City <br /> EHD 42 -04 SEPTAGE CLEANERS REPORT <br /> 10/4/07 <br />