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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 /> Company Name: <br /> SEPTAGE CLEAN ER'S REPORT <br /> � � � � ���. g�s. <br /> rDl/�' Report for the th of: U <br /> Company Address ,�j- j j j year a`d /5� <br /> Signature: <br /> Street Address City � <br /> Zip Code <br /> All information submitted must be Com 3lete accurate and legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE (R) RESIDENTIAL <br /> PUMPED PROPERTY OWNER GALLONS <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY PUMPED GREASETRAP NAME OF TREATMENT <br /> �. 1 CHEMICAL FACILITY <br /> / OUvcity <br /> t r <br /> .503 S. <br /> City '1 571 t i l <br /> Ev� cl > i <br /> cl 1 I <br /> SZ10 /L < <br /> ci 1 ( <br /> ---------- <br /> city <br /> � r <br /> city �w I <br /> city <br /> L �u 6Q10 L-e�o /O /G�►/i <br /> city <br /> city !I ! I L <br /> ci l l <br /> $!.✓ <br /> cit <br /> PL oti — <br /> 2S /3 /Ll f//�ydr�Q/V F t cil a5 <br /> V-4A n 2 .2 Gr/• /c` ci 1, <br /> Rxcity <br /> EHD 42-04 <br /> Page of <br /> 12/27/13 <br /> SEPTAGE CLEANERS REPORT <br />