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RECEIVED <br /> JUN 04 2014 SAN JOAQUIN COUNTY <br /> .t ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 1868 East Hazelton Avenue, Stockton,CA 95206-6232 12'b of each month <br /> ;'. ENVIRONMENTAL HEALTFTP/ephone: (209)468-3420 Fax:(209)464-0938 Web:www.sjgcv_orgJehd <br /> PERMIT/SERVICES <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: Ho►.CH 1 %&Lk,: {' Report for the month of: M0. — year 1014 <br /> ti <br /> Company Address: 104 AA,, foil C16 bu-y ` LI SC57 Signature: <br /> o Street Address City Zip Cade w}*u� Pew 1 �` ZSj•t�Os L 6�� <br /> All information submitted must be complete, accurate, and le Ible �b <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS {R) RESwENML NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED (G) GREASE TRAP FACILITY <br /> PLEASE INCLUDE STREET 8, DIRECTION, STREET NAVE AND CITY C CHEMICAL <br /> L on Hot16 Cro otr Wr + jj 4% c:iv " pp r- 3$ rL Q N1L114 <br /> z <br /> S— <br /> ti S _ 2U r� it cit, !! !r C— <br /> ri <br /> 5=27 <br /> city <br /> c <br /> city <br /> city <br /> city <br /> city <br /> city <br /> City <br /> city <br /> city <br /> Ci <br /> city <br /> city <br /> Page of <br /> EHD 42-0a <br /> SEPTAGE CLEANERS REPORT <br /> 12127/13 <br />