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. z.. •� SAN JOAQUIN COUNTY ��� <br /> ENVIRONMENTAL HEALTH DEPARTMENT i• 17 2016Return this form by the <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 EI 12" of each month <br /> Telephone:(209)468-3420 Fax: (209)464-0138 Web:www.sjgov.o9EWTAL HEALTH <br /> W_&7'13ERjqCES <br /> S��EPTAGE CLEANER'S REPORT <br /> Company Name: �,l)� ��� (�t. ` -s'2e ,(—w <br /> 4 Report for the e h of: year a v/ <br /> Company Address: <br /> i ? <br /> Street Address Signature: <br /> 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 PUMPEDGREASET FACILITY <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY C CHEMICAL <br /> ci .�i9000 U 0 v l <br /> city /SIJU <br /> 6ell Z) <br /> /Q 3 2 7-MM7DidCity 91 vvvo <br /> C ity ' <br /> r/41(0) / i�/ALL Cit <br /> Cit <br /> Cit 0(� <br /> cit <br /> n/ �P1 LSU <br /> W. /�/ ` O cit �j J <br /> b- <br /> /�/ cit <br /> n'l ITD 1p <br /> S o?t1 Gt/ S iZ v of cit 5?JJ <br /> C1li h!� G'vunl / v •�� G�/3��D e� '4�_ —CitylJp <br /> z city � <br /> J. ��v` ��( /0 IAT r✓'Scii'% ��_ <br /> city 3 <br /> Page of <br /> EHD 42-04 <br /> 12/27/13 SEPTAGE CLEANERS REPORT <br />