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SAN JOAQUIN COUNTY RECEIV n <br /> ENv1RONMENTAL HEALTH DEPARTMENT <br /> Return this form by <br /> ` < 600 East Main Street, Stockton,CA 95202-2708 JUN 0 3 2011 the 12th of each month <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.o'g/ehd f <br /> ``FSR SEP A CLEANER'S REPORT ENVIRONMENT EAUMH <br /> ' w Z TISE _Company Name: Report for thof: yea <br /> 1 <br /> Com an Address: ' <br /> p y Signature: �s <br /> Street Address <br /> city Zip Code r j <br /> k <br /> All information submitted must be com tete, aogurate, and le ible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE PUMPED (G} GREASE TRAP GALLONS (R) RESIDENTIAL NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY;; C CHEMICAL FACILITY # <br /> cit <br /> is <br /> 0 / cit <br /> cit <br /> �J7 Cit !{! <br /> rweJ <br /> D5.� 6 � city <br /> =/ I. <br /> � S�v✓ � ci <br /> r <br /> CityC4 . <br /> Ci ti <br /> r <br /> r cit <br /> y <br /> cit <br /> 00, <br /> Cit <br /> . � z . <br /> �. Cit <br /> r f % .✓ �5 3 <br /> Ci <br /> �� ; • r li J cit f / <br /> r <br /> EHD 42-04 Septic/Cesspool Report <br /> �I <br />