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�XEIVED <br /> Qn4Hlty 6'{2+lJY 10 201 <br /> SAN JOAQUIN COUNTY <br /> r ENVIRONMENTAL HEALTH DEPARTMENT ENVIRONMENTAL <br /> � Lrn this form by the <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 PERMIT/SERVI 9i 2t" of each month <br /> Telephone: (209) 468-3420 Fax: 209 464-0138 Web: <br /> ( ) wvvw.sjgov.arg/ehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: �y /%(1� . \ s'Re �Zjy/ ,�(/� Report for the onth of: <br /> p C year ,'.t <br /> Company Address: —5,:50 ,� �'�—� Signature: <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 /> ' % N-Oui{/7EAT�li9a/� 19-. 4/D 4O cit %- &Ao ,j 011e J Y S <br /> ii m�� yyv GI/�i ✓ �p` cit <br /> / 4 n) �� / Yv city <br /> & /V e#'�relyz Cit , <br /> Zz puk Loco a cit <br /> hQ9CL- �UfJi o?2.2c'� ��1��i /r�CE/ ' ✓ cit �a <br /> Cit <br /> cit <br /> cit c� <br /> Cit <br /> 115 -1;7)Lt')H lah4 Cit Il <br /> -11A I /1)-6!U u C �2��5'Gfl �tE . LTJ � l.�?�I/�' cit <br /> S �z A21 e)a /edCSa- cit Il 'DGJD <br /> cit <br /> OL � ' •dig- city r /571 <br /> City <br /> ��J✓GVrr l/9��Gn.l�1r y 5��rs-J/��,�-i?'J,-�—C Cit <br /> Page Zof <br /> EHD 42-04 <br /> 12/27/13 SEPTAGE CLEANERS REPORT <br />