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4 <br /> "'• SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 600 East Main Street, Stockton, CA 95202-3029 1201 of each month <br /> } Telephone:(209)468-3420 Fax:(209)464-0138 Web:wwwsjgov.org/ehd <br /> L� SEPTAGE CLEANER'S REPORT <br /> Company Name: Report for the nth r .2D12 <br /> Company Address: y^P�D� 'y� itQ.i /lfv��6 Signature: <br /> ' Sued Address City LP Code <br /> All information submitted must be complete, accurate, and legible <br /> M DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS IRI REsMENRAL NAME OF TREATMENT <br /> IGJ <br /> PUMPED PROPERTY OWNER PUMPED GREASETRAP FACILITY <br /> ED j PLEASE INCLUDE STREET /, DIRECTION, STREET NAME AND CITY C cNENICAL <br /> Q/1 7city <br /> O <br /> F <br /> city <br /> city <br /> City <br /> city <br /> city <br /> city <br /> city <br /> City <br /> rn <br /> rn <br /> City <br /> o <br /> i C z <br /> 1 ZE <br /> City ¢ <br /> 0 <br /> CRY <br /> rn <br /> Cityr <br /> 0 <br /> Citycr <br /> cityo <br /> LL <br /> Q C <br /> m � <br /> CI <br /> W <br /> CD <br /> city _ <br /> N '— <br />[.mm�i d <br /> SEPTAGE CLEANERS REPORT Y <br /> 19 EHD 42-04 ._ <br /> tDlaoT <br /> a <br /> in1 <br /> f i E%80 <br />