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RECEIVE® <br /> SAN JOAQUIN COUNTY <br /> APR 0 2 2014 ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> i1 600 East Main Street, Stockton, CA 95202-3029 12'h of each month <br /> ENVIRONMENTALHEALTTqlephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> PE 1T/SERVICES SEPTAGE CLEANER'S REPORT <br /> Company Name: // Report for the m th of: year <br /> Company Address: G1 60 y o� Li �2 Signature: If <br /> Fri Street Address city Zip Code <br /> f''.I <br /> All Information submitted must be'complete, accurate, and legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE-WORK WAS DONE GALLONS tRl a>stnENT1AL NAME OF TREATMENT <br /> � <br /> JMPED PROPERTY OWNER PUMPED (G) GREASE TRAP FACILITY <br /> O PLEASE INCLUDE STREET /, DIRECTION, STREET NAME AND CITY C CHEMICAL <br /> city <br /> CRY <br /> C' <br /> city <br /> city <br /> Gity <br /> city <br /> City <br /> city <br /> ` o <br /> city <br /> z <br /> e Q <br /> cityo <br /> cfty <br /> 0 <br /> O N <br /> city <br /> Q Q <br /> l9 C' Q <br /> f•7 <br /> a� <br /> m <br /> city E-= <br /> city <br /> t0 city <br /> fU V <br /> I — <br /> EL EHD 42-04 SEPTAGE CLEANERS REPORT C�wf <br /> OL`■ ■ w.a <br /> ■ ■ ■ ■ ■ <br />