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RECENED <br /> %-JD <br /> � SAN.fOAQUEN COUNTY xTEl <br /> JUL 1,3 1010 ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 600 East Main Street, Stockton,CA 95202-3029 12ei of each month <br /> n • NUf RUNE'MIE! T HEALTH Telephone:(209)468-3420 Fax.(209)464-0138 Web:www.sjgov.org/ehd <br /> `a <br /> PERM ITI � t <br /> _R lIEE SEPTAGE CLEANER'S REPORT <br /> Company Name: Reportforthem year <br /> Company Address: • ignature• <br /> SSreel Address e f Tip Code <br /> co All Inlermation submitted must be cam lets accurate, and legible <br /> CS] DATE NAIVE OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (M RESIDENTIAL <br /> PUMPED PROPERTY OWNER IG1 GREASE TRAP NAME OF TREATMENT <br /> PLEASE INCLUDE STREET 0. DIRECTION, STREET NAME AND CITY PUMPED C FACILITY <br /> tkIEONCAL <br /> o Of? D r c <br /> AYCRY <br /> c• <br /> c' <br /> Chy <br /> Cfty <br /> C' <br /> C- <br /> city <br /> city <br /> c <br /> 0 CRY <br /> L`' c <br /> a- <br /> m <br /> cav <br /> c <br /> ru <br /> m <br /> ED <br /> T <br /> r*� EHD 42-04 <br /> 10!4107 SEPTAGE CLEANERS REPORT <br /> ZDh <br />