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i9 <br /> RECEIVED <br /> ahp,4ly <br /> 's 0 7 2016. SAN JOAQUIN COUNTY <br /> ^' < ENVIRONMENTAL HEALTi- DEPARTMENT Return this#ofrrt by the <br /> -13w 1868 East Flazelton Avenue, Stockton, CA 95205-5232 th <br /> • NT ACESLni Tel {209)46&3420 Fax: (209)4664-0138 Web,VAm.sjgov.crglehd 12 of each mouth <br /> _ ITISERVICES <br /> v SEPTAGE CLEANER'S REPORT <br /> Company Name: <br /> Report for the nth of: ear <br /> Company Address:_ Qp,� C� 0 � <br /> lo� Signature: <br /> .1teetAddess Grty Zip Code <br /> ATI Information submitted must be cornTete accurate, and legible <br /> DATE NAME OF BUSINESS OR (R) RESI MTTAL <br /> PUMPED PROPERTY OWNER ADDRESS WHERE WORK WAS DONE GALLONS ME OF TREATrdENT <br /> w �_ PUMPED (0) GREASETRAP �' <br /> PLEASE INCLUDE STREET k DIRECTION, STREET NAPRE AND CITY FACIL17Y <br /> � C CHEMICAL <br /> W C <br /> <I C <br /> 3 <br /> co Ci <br /> W <br /> <L CH <br /> City <br /> Ci <br /> Cl rn <br /> 0 <br /> C� <br /> L0 • . o <br /> � C�1CID <br /> co <br /> m o <br /> N C-4 <br /> cn r <br /> p� cit <br /> CD <br /> � c � <br /> CD <br /> m �. <br /> N <br /> CD Piga of <br /> �y EHD 42 <br /> 42127M3 <br /> SEPTAGE CLEANERS REPORT <br /> X ■ 0�■ <br />