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� SAN JOAQUIN COUNTY <br /> &D60�o-.` <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 12t" of each month <br /> ,�t Telephone: (209) 468-3420 Fax: (209) 464-0138 Web:www.sjgov.org/ehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: vs /�k Report for theonth of:/l year <br /> Company Address: �� �' f3 ,� ��� Signature: <br /> Street Address City Zip Code <br /> All information submitted must be Com tete_ , accurate, and legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAL <br /> PUMPED PROPERTY OWNER GREASE TRA NAME OF TREATMENT <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY PUMPED FACILITY <br /> CHE CAL <br /> .S?c�Td// JSd� S ltiC'� <br /> city <br /> Cit y��Ll S <br /> k0k) city <br /> Cit <br /> T— 7- kilki City <br /> It K$a 4-1E City <br /> City <br /> Cit <br /> City <br /> ;�S <br /> Cit I <br /> 0 A7 A/ /��� Cit i o�lJl�t <br /> a 3-3 JU ►1 / cit 2;2 <br /> C i( c <br /> �/ <br /> �� ✓�[.� City <br /> as 1 () city L <br /> Cit <br /> Page^�of <br /> EHD 42-04 <br /> 12/27/13 SEPTAGE CLEANERS REPORT <br />