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r <br /> �a pati SAN JOAQUIN COUNTY <br /> "`.. ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Return this form by the <br /> Telephone:(209) 468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd 12t" of each month <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: / �j R��/ '�l� "I 0 <br /> Company Address: <br /> � Report for 7;1th�ol* a <br /> .4111-31.5-e ������ � � ���3� <br /> Street Address city Signature <br /> Zip Code , <br /> All information submitted must be com tete 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 �A� NAME OF TREATMENT <br /> 6 ��Uoh C CHEMICAL FACILITY <br /> 3 G/l/0/G cit <br /> i�Apfi �s <br /> ------------- <br /> , <br /> cit <br /> Cit <br /> vu1 un W 1-14 city alock-i o nj <br /> >7/3G �d y G✓�J'T�i4�ZT� Grp �r i � <br /> City5—lil� J <br /> u cit >c I ! Jul ! <br /> 70 <br /> 1 ✓1 T l�/i LSU/t// <br /> Cit i t r <br /> city <br /> Cit , <br /> a , <br /> City <br /> z- i <br /> —�D Ci I< v I O(J 1 <br /> ------------- <br /> CIte <br /> cit 7 t r 1 t <br /> City <br /> l�I�i'�1V�IL57(0) Tz� //D G,�d% C W G9a1/z�- <br /> cit i <br /> of <br /> E H D 42-04 Page <br /> 12/27/13 <br /> SEPTAGE CLEANERS REPORT <br />