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SAN JOAQUIN COUNTY <br /> L? <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 th <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd 12 of each month <br /> -�,, SEPTAGE CLEANER'S REPORT <br /> Company Name: /1% �'U/U ,� �1 � l/��1 & � <br /> t <br /> - & ?AVa11 Report for the thof: %; <br /> Company Address: / tl / year o7Ur — <br /> StreetAddress f30 Signature: <br /> City Zip Cade <br /> All Information submitted must be Complete, accurate and legible <br /> DATE NAME OF BUSINESS OR <br /> PUMPED PROPERTY OWNER ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAL <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY PUMPED GREASE TRAP NAME FA TREATMENT <br /> 9 C C CHEMICAL FACILITY <br /> City <br /> ity <br /> Fz70- t�'e a X93 f�r9 � ``��/� <br /> city <br /> 67 '5' l <br /> Cit <br /> Cit >/ / <br /> /V m cool -l�3I do10 l.0 �{^,�,�� � r <br /> �� cit <br /> / / / City / <br /> S 3/0 130"i H <br /> �� � � a•-.. �J Cit <br /> Cit /! l I l <br /> /Cis Cit <br /> Cit t � <br /> AIAi <br /> City <br /> rc IV/ f788�/��O%o�G�C7GlL �>� Cit J? ! yys� <br /> A� �l r �v y3 3 sl��n ,I/ ��� /�v, j9v4-1 1,&Xjg�Zs <br /> CitS_ I / <br /> EHD 42-04 Page of <br /> 12/27/13 <br /> SEPTAGE CLEANERS REPORT <br />