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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Idazelton Avenue, Stockton, CA 95205-6232 Return this form by the <br /> "''t Telephone: (209)468-3420 Fax:(209)464-0138 Web:www.sjg0v.org/ehd 12 of each month <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: s <br /> Company Address: ��,35 Report for the th of: 0��� year <br /> Street Address City Signature: <br /> Zip Code <br /> All information submitted must be com tete accurate, and le ible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE �R) RESIDENTIAL <br /> PUMPED PROPERTY OWNER GALLONS <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY PUMPED GREASE TRAP NAME OF TREATMENT <br /> /D C: r a/�td CHEMICAL FACILITY <br /> �St,�v✓�/ /� > c <br /> at <br /> 1� /YIISSiOQ✓�Pi o� 6�1,9z 9// �S' �e✓ .�7�' <br /> cit <br /> Crty <br /> i <br /> i > <br /> cit <br /> a 3 `J�✓ U / L�m u t+�jcity <br /> Lr :T city <br /> lie di✓.9-L' v� �a �° ��/ S' GtJC� <br /> S rid <br /> city <br /> '¢ <br /> city <br /> 5C- Cit <br /> V � Cit / <br /> 1 Cit / c7� <br /> Cit <br /> Cit L' 5- Gve� <br /> ��O 164-r�/f1-i��R�/3 /p /'� cit <br /> SES L7�, <br /> Ci!y <br /> C* <br /> t <br /> Page _of N <br /> EHD 42-04 <br /> 12/27/13 <br /> SEPTAGE CLEANERS REPORT <br />