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p4 Ifs,. <br /> a' <br /> 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 12th of each month <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: tld <br /> Company Address:% <br /> Report for the th of //r�i���� year ��S <br /> Street AddressCity 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 4 DIRECTION STREET NAME AND CITY PUMPED G) GREASE TRAP' NAME OF TREATMENT <br /> FACILITY <br /> CHEMICAL <br /> =� NN Vgrl So»vic,�i m• 75"G��' � = ci �� � dD� <br /> �a3 as iTF AvWd-5 <br /> ci ( 1 <br /> i✓- - �Gtn c��i�^/'T E. City. <br /> H75ul�lniZ cjt '' <br /> Cfty <br /> �l-y i6' ir✓ �� • �F�ls/�i�✓� r/f=. Ci �%C°f�T0�1/ /BOJ c� <br /> t)a ✓� 1lr0w Cit =/ J <br /> J - city-14 <br /> I J <br /> �j �, IiA�U� city <br /> jL <br /> rity <br /> Cfty <br /> ci cjty <br /> >/ <br /> �/-�cl���Fo" �7a� fit/- ✓`�U�J � <br /> 4 <br /> � � �3d2 Gt/r�dT" � Cit <br /> cit <br /> cit <br /> /v� l?9�1�G�/r9-LAS <br /> city <br /> , <br /> EHD 42-04 Pageof <br /> 12/27/13 <br /> SEPTAGE CLEANERS REPORT <br />