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SAN JOAQUIN COUNTY <br /> x ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> y <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 12tH of each month <br /> ......;�*. Telephone: (209) 468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: �l")� �(�/jy�� <br /> Report for the month of:Zee, P,,�/j <br /> Company Address: year <br /> /�.�SC� �C// �- S� �/� c/S �'C� Signature: <br /> Street Address Icity Zip Code <br /> All information submitted must be complete, accurate, and legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS [�G) <br /> RESI ENTIAL NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED GREASE TRAPFACILITY <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY CHEMICAL <br /> Cit <br /> Cit <br /> City <br /> Cit <br /> Mi 177 fS 63e)?p �!/rAel e�/�1/�G.L Cit <br /> %Z 14 l0 70 t/)1 6P LV/•CS(9A) City r <br /> i1 <br /> Z/it 14a d�vtGl /' ;z-7;z <br /> I/V, " I Z- Cit \/ <br /> Cit <br /> 60 UJ '4V" a Cit CIW/ <br /> r 7k- y ��9 N%�� aZ Cit <br /> A `o"'/� /TI/1/G City O <br /> W611XeNu0ii� �'whco City �,01w'. <br /> i DSP19,villiod )01M1nV)q-t1 Cit <br /> y S/7F. R01910 Cit <br /> le <br /> O city <br /> Vgo6V*1'4 Cit <br /> /7TUVW�ce/ udre /�A9/ ,O Cit ( ✓��qvja�Jn <br /> Page of <br /> EHD 42-04 <br /> 12/27/13 <br /> SEPTAGE CLEANERS REPORT <br />