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R"`E C E I V E D <br /> SAN JOAQUIN COUNTY ,JAN 12 2015 <br /> �01o1ri-C6 <br /> r ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> %'- 1868 East Hazelton Avenue, Stockton, CA 95205-6232 ENVIRONMENTAL HEALTH 12"' of each month <br /> •c;. ;r P Telephone: (209)468-3420 Fax: (209) 464-0138 Web:www.sjgov.orcj?EIIT/SERVICES <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: "�CR ` Report for the month of:� a year �J�y <br /> Company Address: 3C� Signature: <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) RES•'DENTIAL NAME OF TRL:,ITMENT <br /> (G) GREA�ETRAP <br /> PUMPED PROPERTY OWNER PUMPED FACII_ff'i <br /> PLEASE INCLUDE STREET #, IRECTION,/STREET NAME AND CITY ,P (C) CHEMICAL <br /> itC ✓2(� / n��vJ C. e42 <br /> cit <br /> City <br /> %'NYif%� ��a7v �/TjyfllL�rYJ(J / 'Q�� Cit <br /> L16Cit —/1D SOJ <br /> 3 Fsi /%lr/y- ✓l/ ii� cit .�Dicvd it <br /> iGt�l 7Si�1/ /Ol/vC�l�Si / �v�/ /,.. *� - Cit >t ✓�O� /r <br /> I <br /> WIVE k0 'SI& {/�s T/l 0191V Cit <br /> s,�l �GRiII R6 Sum SCCl-1�dll/ City �i sv ii <br /> Cit <br /> City <br /> / auaT <br /> �!7 / /%. 0 - 7 /✓ �% f�✓l�i� /`1U'6l✓�� Cit <br /> 7� rn/ /� l� / rYJ�_.'!l 11/� cit <br /> pp ryl� Cit 1t SCJ r r <br /> City 5�O <br /> 24-2) Alela <br /> x)0gid kok�r Lw <br /> Cit <br /> Page _of <br /> EHD 42-04 SEPTAGE CLEANERS REPORT <br /> 12/27/13 <br />