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ar,4ultY. � <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> %'• ' Return this form by the <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 12t" of each month <br /> Telephone: (209)468-3420 Fax: (209)464-0138 Web:Www.sjgov.orglehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: j),y ll?1I- �/�� i Z �//- Report for the nth of: �64Z years/� <br /> Company !address: ��� Signature: \ <br /> Street Address Clty Zip Code <br /> All information submitted must be complete, accurate, and legible <br /> DATE NAME OF BUSINESS OR (R) RESIDENTIAL <br /> PUMPED PROPERTY OWNER ADDRESS WHERE WORK WAS DONE GALLONS ——GREASE TRAP PUMPED NAME OF TREATMENT <br /> ` <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY CHEMICAL FACILITY <br /> Cit <br /> Cit <br /> T2s 3�v usiiT� City <br /> i 7 v/ low 730 Z VtTfoV/� Cit <br /> Cit <br /> o?015-0 44 vi.,E j7-/4 k Cit ) <br /> ZAN �24' k)- ���s—/�/ T us e r� Cit >1 vv <br /> —i�— <br /> Cit <br /> .32L/3W m✓' city T:r A) <br /> Ij9 AItC /Ude S �S/2E�% <br /> City AAD "t <br /> IOS iG LA7 l�2. Cit <br /> Cit / 1 1 <br /> City <br /> a) A. <br /> 1311 Cit <br /> f RG 70 L11W�Awe// City <br /> mac' r <br /> at <br /> cit ' 31Lld c <br /> Page of <br /> EHD 42-04 <br /> 12/27/13 SEPTAGE CLEANERS REPORT <br />