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DECEIVE® <br /> o�q�IK•.c SAN JOAQUIN COUNTY <br /> x•e,tba'•,o <br /> z , l C 16 2015 ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 12t1' of each month <br /> *NMENTALHEALTH Telephone: (209)468-3420 Fax:(209) 464-0138 Web:www.sjgov.org/ehd <br /> ' <br /> PERMIT/SERVICES <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: 15*,'W"/Zl 1S��r1��/C1A1�i-1 (b- /,ew <br /> 15A(V DZdll� Report for the ria-oi�th of: ?year .amu/S <br /> Company Address: ��✓�� /G��/� 63 Z. —Qfv,& jn /TGSignature: � <br /> Street Address city Zip Code <br /> All information submitted must be complete, accurate, and legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAL NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED GREASE TRAP FACILITY <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY (C) CHEMICAL <br /> li 2 /.5 Z, )N62-rin4fr 1S2V0 Aw ,,O cit !� d <br /> /3 lav IWlg,2 yo Gtr/ A4V Cit li no �sa� 1 <br /> city <br /> 119WL�F cit <br /> Cit <br /> ��- ks - ata �. / -r6f o Cit ova I I <br /> 1/ IOU o W�i L ` cit j C c <br /> cit w o Sm-j7i seS� r�?3 It cit <br /> City <br /> � <br /> < < <br /> acs t r l <br /> Gt'�D��✓ �S o"i3�a G(/Es�" i cit 570 c <br /> Cit > <C ► / <br /> cit <br /> o/ cit <br /> ;?;UA) L (Pv�S` �, I�a/� City <br /> BOAof r,,--- Cit �� �� it <br /> e�M 1q FM 0%h/f'/L 24&L-72; 24—L <br /> Page _of <br /> EHD 42-04 SEPTAGE CLEANERS REPORT <br /> 12/27/13 <br />