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RECEIVE® <br /> Q�aul�. <br /> r` SAN JOAQUIN COUNTY OCT 0 9 2015 <br /> • it ;` ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-623JENVIRONMENTAL HEALTH Rehurn this form by the <br /> Telephone:(209)468-3420 Fax: (209)464-0138 Web:wwW,sjgov.r�'r�fAq/SERVICES �2 of each month <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: �� 4�V1owm'A Cit), all <br /> Company Address: 11056 .moi= i/V Report for the month of: /. year�0/,S <br /> QUO ' /YJ/�TlU 95 d ----- <br /> StreetAddress city Signature: <br /> Zip Code <br /> All information submitted must be com lete accurate, and le Ible <br /> DATE NAME OF BUSINESS OR <br /> PUMPED PROPERTY OWNER ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAL <br /> 9 PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY PUMPED GREASETRAP' NAME OF TREATMENT <br /> C CHEMICAL FACILITY <br /> Ji/-�✓- �,. c �a No <br /> cit <br /> / z,-F7, <br /> 10 Cit o� <br /> �90✓t� <br /> go, City. <br /> City <br /> ! / ' Ic <br /> /97 <br /> Cit cp <br /> c. Oldt l 1 <br /> Cit <br /> Cit <br /> C't I I J r5 U <br /> t <br /> cit 7I I <br /> / L L <br /> cit <br /> c-G�c2t <br /> cit ! LJ ? 2 <br /> Cit J l i <br /> cit ! / <br /> �.vr>t�ar 3 yap 4 <br /> Cit <br /> IF !/E cit rl� <br /> /1 <br /> � S�C� it tt <br /> of <br /> EHD 42-04 Page <br /> 12/27/13 <br /> SEPTAGE CLEANERS REPORT <br />