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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by <br /> 600 East Main Street, Stockton,CA 95202-2708 the Return <br /> of each month <br /> Q Telephone:(209)468-3420 Fur:(209)464-0138 Web:www.sjgov.or;g/ehd <br /> SEPTAGE EANER'S REPORT <br /> Company Names \ <br /> Report for the nth o : earQ � <br /> Company Address: r . <br /> wl <br /> Street Address ity Signature: <br /> p de '� <br /> All information submitted must be colulete, accurate, and Illegible <br /> DATE NAME OF BUSINESS OR <br /> PUMPED PROPERTY OWNER ADDRESS WHERE WORK WAS DONE GALLONS �R) RESIDENTIAL NAME OF TREATMENT <br /> PLEASE INCLUDE STREET A, DIRECTION, STREET NAME AND CITY � PUMPED (G) GREASE TRAP FACILITY <br /> � ��+� � �" ��� � .�.�5/✓� I J (C) CHEMICAL <br /> G <br /> CiLy 0) <br /> City <br /> ) <br /> /� � � % 3. l��k�' Cit �� .� �—(�Y�-� � c��!/F✓ <br /> City <br /> Cit <br /> Ci <br /> Cit <br /> City <br /> city <br /> a <br /> Ci <br /> Ci <br /> Cit <br /> City <br /> Cit t <br /> ci <br /> 'City <br /> Cit <br /> EHD 42-04 <br /> kSeptic/Cesspool Report <br /> I <br />