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SAN JOAQUIN COUNTY <br /> z ENVIRONMENTAL HEALTH DEPARTMENT <br /> "`._ `�t 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 /> SEPTAGE CLEANER'S REPORT <br /> Company Name: tZM IW Report for them th A: i� year cZ G <br /> G � Y <br /> Company Address: �� �C/ �� ��� Signature: <br /> Street Address City Zip Code <br /> All information submitted must be Com p tete, accurate, and Ie Ible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAL NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED GREASETRAP FACILITY <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY C CHEMICAL <br /> **L350 1/ . s/I LIW16- ai—oe 5d S <br /> kMAVUIC Q;� ��r9r-16RID 0610 <br /> RAO o' D �i1U� CJS <br /> City -5— <br /> &d <br /> Teo IVl iS G= nSco�,i/� Lid s Cit c <br /> W- Elie)Vuci6 k)1W Cit l CvL) <br /> / W W• $�d�UC i� (��� Cit U <br /> r <br /> Jai D Cit <br /> /� J lilt. l Tlt S% cit ' <br /> 4eL'/9))b e,o oZ 1 Cit / <br /> T/U9NG (Im. d. J o & cit <br /> of / E <br /> cit <br /> IILL&YJ S 1/T-U S cit 1 <br /> T/1 Cit (� <br /> city L �l <br /> I �J / - �W t /Z. cit () <br /> city <br /> Page of <br /> EHD 42-04 <br /> 12/27/13 SEPTAGE CLEANERS REPORT <br />