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�. SAN JOAQUIN COUNTY RECEIVE <br /> ENVIRONMENTAL HEALTH DEPARTMENT 1 L��,/ V G Return this form by <br />' 600 East Main Street, Stockton,CA 95202-2708 the 12`b of each month <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd DEC 08 2011 <br /> LtFOR� <br /> SEPTAGE CLEANER'S REPORT ENVIRO A+Ept- H TH <br /> Company Name: Report for mo yea& <br /> Company Address: 4LbSignature <br /> ftS�t 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) REsmENTUL NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED (G) GREASE TRAY FACILITY <br /> PLEASE INCLUDE STREET k, DIRECTION, STREET NAME AND CITY (C) CREMcAt <br /> c; o <br /> Ci <br /> a 3p�' �G O <br /> 6 <br /> ® L ca God <br /> city 000 049 <br /> S <br /> o ci O G S7K/ <br /> a <br /> Ci , d0 <br /> y� o c cityG..,, <br /> Ci <br /> tya <br /> City <br /> city <br /> — Q CityoV <br /> ' c. r .0 <br /> �J�jJ sA.1-L =S Z6') Ci <br /> t"/i �l/�/•a ' Ci <br /> ERE)42-04 <br /> -- ---- Septic/Cesspool Report <br />