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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 12th of each month <br /> Telephone:(209)468-3420 Fac:(209)464-0138 Web:www.sjgov.org/ehd <br /> P <br /> 9�tFOft SEPTAGE CLEANER'S REPORT <br /> Company Name: Report for the ont yeah_ <br /> Company Address: 1 ' Signature: <br /> 6(-Aedd City ip ode .a <br /> All information submitted must be complete, accurate, and legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAL NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED (G) GREASETRAP FACILITY <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY C C�mCAL <br /> city 7 <br /> a <br /> city c AV- <br /> f AA <br /> city <br /> Cit <br /> `Y.� % /O✓'.fin <br /> city �� �✓ i <br /> r <br /> -t n prl/ L <br /> city <br /> s t+ Cal'' ✓ t.d /Pi <br /> Ci n i `y tJ e �7 <br /> city <br /> city <br /> Ci <br /> Ci <br /> City <br /> City <br /> City <br /> City <br /> city <br /> City <br /> Cit <br /> EHD 42-04 <br /> Septic/Cempool Report <br />