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+.....' JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 600 East Main Street,Stockton, CA 95202-3029 12t" of each month <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web. www.sjgov.org1ehd <br /> SEPTAGE CLEANER'S REPORT 1.2 r A o 2Company Name: Repo or the:mnih 01:," Q40 yoar <br /> L <br /> ! 'v f'cn SA P11 <br /> Company Address: ;3( 5�Szp3l)—s[gnature: j <br /> Simel Address Gity Zip Code <br /> All Informallon submitted must be complete, accurate, and legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS RS' ENTWL NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED GREASE TRAP FACILITY <br /> PLEASE INCLUDE STREET M. DIRECTION, STREET NAME AND CITY CHEMICAL <br /> I�PE D] <br /> Ci <br /> city <br /> City <br /> CHY <br /> city <br /> icity <br /> Citv <br /> cdy--. <br /> city <br /> Giky <br /> Ci <br /> City. <br /> City <br /> aty <br /> ctr <br /> Civ <br /> City <br /> city <br /> EHD 42-04 SEPTAGE CLEANERS REPOR7 <br /> AW4107 <br />