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RECEIVED <br /> Q,,gkl!y JAN 12 2017 <br /> " c°ti SAN JOAQUIN COUNTY <br /> z =NVIRONMENTAL H <br /> ENVIRONMENTAL HEALTH DEPARTMENT SALT Return this form byjthe <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 PERMIT/SEROCES <br /> Telephone:(209) 468-3420 Fax:(209)464-0138 Web:www.sigov.org/ehTelephone: of of each month <br /> SEPTAGE CLEANER'S REPORT ' <br /> Company Name: ��� n vs i� �: <br /> Report for the snth <br /> Company Address: �.jj "' <br /> Stleet Addr. Signature: <br /> City Zip Code _ <br /> All information submitted must be com lete, accurate, and legible <br /> DATE NAME PE BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS <br /> PUMPED PROPERTY OWNER (R) RESIDENTIAL NAME OF TREATMENT <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY PUMPED 4G GREASETRAP; <br /> �'?'I�/(� s� C CHEMICAL FACILITY <br /> -�✓-Oul_ �v ci i a .`5 OOc) <br /> bZ �i4iYl6t/z�'S <br /> 1 /�0 e4. y�z 0 <br /> ci <br /> city `/moo (.}. b 0 <br /> Cit <br /> . � city <br /> gre city�1 /C,6,CVIZQ �. 19 <br /> Mid 23/ <br /> city �I <br /> N-�UGrl / G / / cit ! I / <br /> G��/,(�ii'r/7✓ <br /> Cit), <br /> Cit 1( <br /> ISS Z L C- /3 D/S'vY2 Cit <br /> h SOI) <br /> Cit / <br /> ld"f cit <br /> city <br /> N Si01� /U4�d AW7—A 0� 45We cit <br /> cit / moi <br /> � <br /> EHD 42-04 Page —of <br /> 12/27/13 <br /> SEPTAGE CLEANERS REPORT <br />