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• ar,4tliTy o <br /> SAN JOAQUIN COUNTY <br /> ' < ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 12ti' of each month <br /> Telephone: (209) 468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: Report for the-month of:�/� year G/ <br /> Company Address: �3� �� <br /> Signature: <br /> Street Address City Zip Code <br /> All information submitted must be Complete, accurate, and legible <br /> DATE NAME PE BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS �R) RES!___-ENT_ I� <br /> PUMPED PROPERTY OWNER GREASE TR NAME OF TREATMENT <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY PUMPED C CHEMICAL FACILITY <br /> ,7>�0� W / �� <br /> Cit <br /> ri/% V S /0 �7/� ��o✓CC� Cit >/ �JU� i I <br /> 8a 116 w <br /> L 1�/ / City U t <br /> U d e i ,U l�f (�®� /� [�vi r!S�N Cit <br /> City <br /> Or 44)?'S'rA4 kq�/i-7- Cit <br /> J (f'✓1I � �� ��� J��T-.�J� Cit <br /> `� Cit <br /> / G, <br /> NTI� �U �`' Tcit <br /> 1 / JAG C 1 1 <br /> /AJ 9 0y, xi c/-/- ' Cit <br /> Cit <br /> -2 /�GIJT Cit <br /> 7G/ /�11t''%�C J-T cit ,� 7 OUC <br /> - ikJ Z7� (�(/• / 4alel Cit A4 94 1oJ <br /> City of R !/f/ <br /> 0 d cit l !� > 1 <br /> city <br /> Page of <br /> EHD 42-04 <br /> 12/27/13 SEPTAGE CLEANERS REPORT <br />