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_ .... . SAN JOAQUIN COUNTY RECEIVED 1 <br /> i ENVIRONMENTAL HEALTH DEPARTMENT Return this form by <br /> < 600 East Main Street, Stockton,CA 95202-2708 the 12"'of each month <br /> Telephone.(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.orgleo,� 10 2012 <br /> R4`I` SEPTAGE CLEANER'S REPORT <br /> ENVIRONMENTAL HEA � \ <br /> Company Name: Reporpfdilf6lS66 earJ1� <br /> Company Address: l 's 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) msIDENTTAL NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED (G) GREASETRAP FACILITY <br /> PLEASE INCLUDE STREET e, DIRECTION, STREET NAME AND CITY CREwCAL <br /> o d Z S <br /> r �p ci <br /> 3�sd <br /> City - Uo <br /> t^/ ci 'L�O1J <br /> o S L av <br /> city <br /> C4 J^ i � <br /> city <br /> City �Oo <br /> City <br /> fCity <br /> l <br /> city <br /> s� <br /> City '�e <br /> citya o ,S7a' <br /> c U G d <br /> cityD <br /> 3-II acJ o !�/ Z5'oo <br /> city -j <br /> ERD 42-04 Septic/Ceaspool Report <br />