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ECEIVE <br /> �gu1 SAAB JOAQUIN COUNTY JAN 0 6 2017 <br /> EhNIROldfutE�1TALHEkLTH DEPARTMENT Return this form Iby the <br /> 1868 East Hazelton Avenue, Stockton,CA 95205-6232 ;ENVIRONMENTAL HEALTH 72�' of each rrtortth <br /> Telephone:(209)466-3920 Fax:(209)464-4138 Wets:wwvr.sJ90v.0r0IT/SERVICES <br /> { ;V <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: ' Report for the o th of: .C-. year }�O <br /> Company Address. O Signature: <br /> 51re Address / Zip Code <br /> All information submitted must be complete, accurate, end le ible <br /> GALLONS ERS RESI9E11T]AL tdAFr4E OF TREATMENT <br /> DATE NAME OF BUSIAESS OR ADDRESS WHERE WORK WAS DOME PUMPED {G) GREASETRAP FACILITY <br /> PUMPED PROPERTY OWNER PLEASE INCLUDE STREET Q, DIRECT10h1, STI?EfL NAME AND C17Y (C) GHEWCAL <br /> � J n k My <br /> J <br /> Z <br /> c <br /> VIV Gig- <br /> J. c <br /> `. <br /> <7 cit' <br /> `3 u <br /> Gity <br /> �JL C <br /> u zc' city <br /> city <br /> city <br /> l `k o <br /> u <br /> city <br /> Cly <br /> Cit' <br /> CU Page of <br /> SEPTAGE CLEANERS REsC)RT — <br /> EHD 42-D4 <br /> 12!271 t3 <br />