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QRnul�r, ° SAN JOAQUIN COUNTY <br /> .=.rte-�-•.a <br /> Z. ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-623212th of each month <br /> . Telephone:(209) 468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: �6 4 '-I-!/ SCJ- Report for the month of: ear w <br /> Company Address: /��� ✓ Signature: L/ <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 GREASETRAP FACILITY <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY (C) CHEMICAL <br /> /' �J C�t cV <br /> ✓ x&4"f � U 1 ^ -�r�i 1�G,L�/Ti kj / cit <br /> � V <br /> 4 S iF ,T / i2C�/ City <br /> v PCs <br /> Cit �+ <br /> Cit <br /> F as-��-c� .�vu�f Cit <br /> Cit <br /> Cit 11t <br /> &124 .> . !aL- Cit I / <br /> 6 4 6 qcd Cit <br /> C it <br /> Cit <br /> Cit <br /> Cit <br /> City <br /> Cit <br /> Cit <br /> Page of <br /> EHD 4.2-04 SEPTAGE CLEANERS REPORT <br />