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��s6ti 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 12 of each month <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: o y�'��v i� �„ � 5 <br /> Company Address: /3S� ,BL Report fort m nth of: <br /> .�� � ���— year <br /> Street Address cltY Signature: <br /> Zip Code <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 GALLONS (R) RESIDENTIAL <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY PUMPED GREASE TRAP NAME OF TREATMENT <br /> C CHEMICAL FACILITY <br /> City <br /> city <br /> Atcity <br /> city <br /> la8� CC/ i 1t/�v ROM city l <br /> S. �GJ�Sr ;/�L i UlJ <br /> —41 <br /> h� <br /> cit // JCC <br /> 11 <br /> ity <br /> r✓40 l� ? / <br /> 8G (� Gthtl�il�� ✓l71 ,gp -C!! <br /> Gt D Qn/6L✓VlC 1JYl ✓✓CE7/Ec / <br /> y3l�/�d� Cit <br /> i��✓ 171 �Ve cit <br /> Cit <br /> Cit <br /> cit <br /> at 4504) <br /> Page of <br /> EHD 42-D4 <br /> 12/27/13 <br /> SEPTAGE CLEANERS REPORT <br />