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Qr441!y. '��CEI VED <br /> r_c <br /> SAN JOAQUIN COUNTY SEP <br /> ENVIRONMENTAL HEALTH DEPARTMENT r 2015 <br /> 1868 East I-lazelton Avenue, Stockton, CA 95205-6232 �RpNM�N Return this form by the <br /> `'<«aa�`}• Telephone: (209)468-3420 Fax: (209) 464-0138 Web:www.sjgov.oPy 12 of each month <br /> ��'141TjSEgVIC�tT/.� <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: ���`C/'�l'I/� � //✓ �0- bP>,�' ,� <br /> Company Address: / ('" �. Report fort nth of: CGCcI T <br /> �OGL� ,�r�G year <br /> Street Address i <br /> City ZZl%p Code Signature: <br /> All information submitted must be com lete, accurate, and legible <br /> DATE NAME OF BUSINESS OR <br /> PUMPED PROPERTY OWNER ADDRESS WHERE WORK WAS DONE (R) RESIDENTIAL <br /> PLEASE INCLUDE STREET d, DIRECTION, STREET NAME AND CITY GALLONS NAME OF TREATMENT <br /> T/ PUMPED GREASE TRAP <br /> ✓V (C CHEMICAL FACILITY <br /> �" 5 oSvu <br /> x�✓ A <br /> 111 8 924/0 <br /> ...,t/✓-✓V- t� <br /> Cit /t l 6--b6--b <br /> sv� <br /> �/fiv O city. I1 ' <br /> �y c t GoC?fC��=U�4' <br /> ,t/ U 4—a l s <br /> City 4) t <br /> zG/dc7.0 n aZ� .�Uuil� Sc�lvv� S%s2 c;City <br /> r/ <br /> City <br /> Cit <br /> Cit <br /> cit � <br /> cit <br /> C Cit p <br /> U P)Af / I <br /> W /aZ City <br /> �v t/Glff�s@15�tJllC oS/%� <br /> Cit <br /> EHD 42-04 Page_ LOf > <br /> 12/27/13 <br /> SEPTAGE CLEANERS REPORT <br />