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it <br /> RECEIVED <br /> nn SAN JOAQUIN COUNTY <br /> Gks <br /> T I 1 2017 ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> ENVIRONMENTAL HEALTH 1868 East Hazelton Avenue, Stockton, CA 95205-6232 12th of each month <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> PERMMSERMES <br /> SE!PTAGE CLEANER'S REPORT <br /> Company Name: Report for the o of: yea �U l <br /> Company Address: U 3�4Signature: <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) RESIDENTIAL NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED (G) GREASETRAP FACILITY <br /> t LEASE INCLUDE STREET #, DIRECTION STREET NAME AND CITY C CHEMICAL <br /> e city <br /> Cit <br /> city 6 <br /> S <br /> f l v 1 <br /> C ty D/I <br /> L( L7 e v <br /> ( d G cit v -P `{ <br /> In q, I Z IV- CityLie <br /> Cit <br /> Cil <br /> cit <br /> city <br /> city <br /> Cit <br /> �Il <br /> city <br /> -city <br /> city <br /> Page of <br /> EHD 42-04 SEPTAGE GLEANERS REPORT <br /> 12/27/13 <br />