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4.68,1-N JOAQUIN COUNTY <br /> C j�E ENVIRONMENTAL HEALTH DEP <br /> ARTMENT "k Return this form by <br /> 600 East Main Street, Stockton,CA 95202-2708 <br /> cq�fFoixe��4 Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov. rg/ehd the 12`s of each month <br /> MAR 1.5 2011 <br /> SEPTAGE CLEANER'S REPORT <br /> Company NameENVIR <br /> T t X11. 44 <br /> Company Address: ��' Rep rt fo9- <br /> All <br /> onth of: ear 1 <br /> S9 <br /> Street Address ` ' yry ; <br /> city Siglgture , <br /> iuforination submitted must be complete, Zip code {h��i 1 <br /> asccurate, and le ible �� i <br /> BATE NAME OF BUSINESSOR <br /> PUMPED - � <br /> PROPERTY OWNER ADDRESS WHERE WORK WAS DONE GALLONS (R) PESIIIENTIAL <br /> PLEASE INCLUDE STREET N, DIRECTION, STREET NAME AND CITv',: NAME FA ILITY NT <br /> J PUMPER ��'� GREASE TRAP <br /> (C) CHEMICAL FACILITY <br /> �. � � � � � � city f�„��.�✓ �� � /� ��./ 5��� �k <br /> j f <br /> City <br /> �- CrCrl�'/ ✓P� Cit -��[� �r��=i!'� <br /> Ci <br /> �. �City z- <br /> City f1. 5�� e / I <br /> Cit <br /> cit ✓ <br /> 7 <br /> Jar I <br /> c� •� fi .� �� � � �� ..tom � <br /> Ci <br /> EHD 42-04 Cit <br /> Y <br /> t,� ji Septic/Cesspool Report <br />