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t44t I N <br /> 'a SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 12t1' of each month <br /> Telephone: (209)468-3420 Fax:(209)464-0138 Web:www.sigov.org/ehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: GG �s /!UC s�C Lary/ Report for the nth of: year 6� t)14 <br /> Company Address: <br /> street AddressCity Code- Signature: <br /> Zip <br /> All information submitted must be com lete, accurate, and legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAL <br /> PUMPED PROPERTY OWNER CREASE TRAP NAME OF TREATMENT <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY PUMPED (C CHEMICAL FACILITY <br /> �T cit <br /> 4✓N-(,2i��� F -22 U1, , ' / City <br /> � <br /> / wz / % IN City ! ) <br /> i�►7- do yeas" c� L 1 ` . Cit <br /> cit i 5 <br /> �ad�✓�C� —Z U 44? 115*le Cit <br /> U Ut/; Cit >( �7✓U I �l <br /> ?✓ Cit < r <br /> Azel <br /> �r� Cit 41 <br /> 4N Y • / Cit <br /> 14. Avv'� .L u /a3 /%iNi1 �1 1�ZvtJ_A4acit / / c <br /> S7�.5 SILL' a L) ST/ Cit / l j <br /> C�vvG Cit / oJy c i 1 <br /> city 162)J <br /> ly/iGrl� �� city IiI / / <br /> City �d <br /> Cit � � ,avv���DDGIkSs <br /> Page_a of :,6 <br /> EHD 42-04 <br /> 12/27/13 SEPTAGE CLEANERS REPORT <br />