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�qultr SAN JOAQUIN COUNTY <br /> a. <br /> � �ba Cati <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 12t" of each month <br /> rt;• ;�P Telephone: (209) 468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd <br /> ct�a <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: y l� �. �B SRC i f N Report for th nth of t'6rrl,8i/L year_3 <br /> Company Address: �,3�C77�r��� (s3r�l,C X420 &� AJC--� Signature: 2/ _ <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) GREASE TRAP FACILI`Lf <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY (C) CHEMICAL <br /> City Od IZs Ae <br /> d 1/2 <br /> .�s <br /> Cit <br /> r / / /,3 0 X734!!/> City <br /> City t t I <br /> 4 !l—eL, zk-- Cit <br /> G City eo t <br /> d` y J - : r CJ Cit <br /> G //0 GtJ D✓! /ZS Cit !� /56)L) i J <br /> j'1/^�/�DygCaS 3/ it/ lnl'41 Cit /� 67a ! I <br /> In X. 1249 Cit f� SG'U '!/"141 f-s <br /> ! !/ 1--- Jl <br /> A7/ C 1 VV Z Cit <br /> i!�,z 1-4-I/Z- Cit �i <br /> 3-) D` Ir✓,IS> ,� Acwz Cit <br /> /l�D�Z111.4S-0 41l Cit <br /> / &L� City <br /> . � ERPL. C7�7 cit <br /> City 6aj l <br /> Page 'z of <br /> EHD 42-04 SEPTAGE CLEANERS REPORT <br /> 12/27/13 <br />