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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by <br /> ' 600 Hast Main Street, Stockton,CA 95202-2708 the 12"'of each month <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> 4{`Fotx� SEPTAGE CLEANER'S REPORT <br /> Company Name: Rep brt fo4theth of: yea>��CompanyAddress: t signature <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 OWER PUMPED (G) GREASE TRAP FACILITY <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY (C) CHEMICAL <br /> city <br /> city <br /> cit y <br /> S ? <br /> City <br /> city <br /> city <br /> Cit <br /> city <br /> Cit <br /> City <br /> city <br /> City <br /> Cir <br /> t <br /> city <br /> Cit <br /> Citv <br /> Ci <br /> Cit <br /> EHD 42-04 Septic/Cesspool Report <br />