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Q,,ault+. <br /> z' SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East I-Iazelton Avenue, Stockton, CA 95205-6232 Ret <br /> this form by the <br /> `'' Telephone: (209) 468-3420 Fax:(209)464-0138 Web www.sigov.org/ehd 12 of each month <br /> SEPPT,AGE CLEANER'S REPORT <br /> Company Name: 77 � <br /> Company Address:/��� �j`�rG� .�L-, ;� � � � 1 <br /> Report for the nth of: JCI L year-;?!��/ <br /> Street Address city Signature: v. <br /> Zip Code „ <br /> All information submitted must be Complete, accurate, and legible <br /> DATE NAME OF BUSINESS OR <br /> PUMPED PROPERTY OWNER ADDRESS WHERE WORK WAS DONE GALLONS lR) R rl-�L <br /> G) GREASETRAp NAME OF TREATMENT <br /> PLEASE INCLUDE STREET # DIRECTION STREET NAME AND CITY PUMPED FACILITY <br /> CHEMICAL <br /> cit <br /> city /�'Uv <br /> c <br /> zoo/ <br /> City / ,j v r <br /> cit <br /> 1 ) <br /> 1866W0,6 <br /> i ,CcS S7Jc/ I <br /> city <br /> ( LJ� J73 d U �' cit <br /> 13� 67. �/� � <br /> c �T(/fG Cit <br /> 7t tl <br /> city <br /> cit <br /> </ <br /> Cit <br /> � l <br /> cit I <br /> ZI Ta Mix. 171,f F. �/��z �� City( 42-ULL <br /> Cit / 57Jv r <br /> EHD 42-04 Page Of <br /> 12/27/13 <br /> SEPTAGE CLEANERS REPORT <br />