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o\ SAN JOAQUIN COUNTY ` <br /> ? ENVIRONMENTAL.HEALTH DEPARTMENT Return this form by <br /> I 600 East Main Stre11 <br /> et, Stockton,CA 95202-2708 tti <br /> the 12 of each month <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> • � \P <br /> SEP E CL ANER'S REPORT ' z <br /> Company Na Report for the onth of- ye <br /> r <br /> Company Address: 1 Signature• ' <br /> Street Address City Zip Code <br /> All information submitted must be comidete. accurate, and legible '. . <br /> DATE NAME OF BUSINESSIOR ADDRESS WHERE WORK WAS DONE GALLONS ) RESIDFNTIAL NAME OF TREATMENT j <br /> PUMPED PROPERTY OWNE PUMPED (G) GREASE TRAP FACILITY <br /> PLEASE INCLUDE STREET N, DIRECTION, STREET NAME AND CITY (C) CHEMICAL 3 <br /> r /T�Cj�J]?(� ✓ jQ/ Ci <br /> l�1 e��6 1 J 7 Cit <br /> Cit / <br /> Ze& City <br /> ' tri <br /> c7e, <br /> 977 e� Cq / � <br /> t 1 <br /> 7Z �7' i ^i 7n Cit c5' <br /> 7 t_ ez/a <br /> x <br /> I <br /> l Ci 6 G 5� <br /> Ci Ar <br /> Cit /� � <br /> Ci �/��� �G a <br /> city : •� <br /> f j Cid S <br /> i <br /> Gv � L J' 6, cit <br /> EHD 42-04 " <br /> --- Septic/Cesspool Repoli <br />