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o!R�1ly c SAN JOAQUIN COUNTY <br /> 2 ` ENVIRONMENTAL HEALTH DEPARTMENT 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.org/ehd <br /> S�EPTAGE CLEANER'S REPORT <br /> Company Name: /�l�< Lx'. �2� «iYI I;dl Report for th nth of:4'&1-'n6& year <br /> L_ <br /> Company Address: �3 '�W� ,� i Signature: alkl <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 CJ CHEMICAL <br /> city <br /> �D S Cit > > Od>] <br /> s�1gC�i—i �ircf ' City <br /> �oo � Cit <br /> �l TD/ 1 v to _ Cit / <br /> city <br /> City <br /> 1�6729s—IV)'"P6/)I/- Cit / <br /> Cit ( O!/ <br /> �✓- X727 VI/. C/ Cit <br /> 1 /C /9P/ . City 0 <br /> I 41QIIUL City <br /> city <br /> Atwe / 1/ / ✓k .'r cit �� S00 <br /> Le /Q�1 WA0 City <br /> r�0- l!L�� cit a�0 <br /> VIA D l-/I/ City -;410 <br /> Page of S <br /> EHD 42-04 <br /> 12/27/13 SEPTAGE CLEANERS REPORT <br />