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_ SAN.IOA4UINCOUNTY RECEIVE <br /> ENVIRONMENTAL HEALTH DEPARTMENT \M/ eturn this form by the <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 12th of each month <br /> Telephone: (209) 468-3420 Fax: (209) 464-0138 Web:www.sjgov.orglehtEB 420,1F <br /> SEPTAGE CLEANER'S REPORT <br /> f ENVI ��A�' � <br /> Company Name: i Report fopj�NMNME year <br /> Company Address: �� `1qo CA 9� Signature: � ��,lfi <br /> Street Address City Zip Code <br /> All Information submitted must be complete, 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 #, DIRECTION, STREET NAME AND CITY C) CHEMICAL <br /> CIt <br /> city <br /> Cit <br /> Clt <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> CIt <br /> Cit <br /> Cit <br /> City <br /> city <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> CI <br /> EHD 42.04 8' SEPTAGE CLEANERS REPORT <br /> 10/4/07 <br />