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?'��' •a� SAN JOAQUIN COUNTY <br /> t ` ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 12tH of each month <br /> r4�«�R�:r• Telephone: (209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd <br /> ��^^11SEPTAGE CLEANER'S REPORT <br /> Company Name: ��� / C:YJ Report for the month year <br /> Company Addres s: �� 3 C% 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 R sl TIAL NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED G GREASETRAP FACILITY <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY (C) CHEMICAL <br /> dnto-wn,Ftge S'/ cit Cr sj/G'U� t7/IfAG � <br /> &v mmj Cit <br /> L R)//0 30 E- D % e 14 city <br /> Wjjq763 J (',T I -e WAE C it <br /> l3 yy� I u h9, -P'/(2s/tel/ i cT6wi-/1w Al/l c ity ado <br /> Cit <br /> city �/���t / /l )< c <br /> ��%v �y/ OZL/v�//t/�� /�Y�✓� Cit ve/G ,q �a !/f/C/C-- <br /> o <br /> -RC/3 9 i�1.��h1l.-J&" cit r I t r r <br /> N&' ID 44.I oZ 5L3 4$M6 cit <br /> ( � -i>(A;5 —P')0 1-9W cit <br /> , �nv� Cit <br /> ash <br /> City �� 5•� /t 1 ` �� <br /> 15000 13 E i rsv? Cit <br /> h 'u ' , a9 City <br /> !/ l�YOV Cit / S�O t 7/ <br /> 3 /Y/res%/ '/� L.sa✓� cit / slly l C/ <br /> Page__R ofd_ <br /> EHD 42-04 <br /> 12/27/13 <br /> SEPTAGE CLEANERS REPORT <br />