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a4g41h. <br /> z' SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> Return this form by the <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> i2tn of each month <br /> Telephone:(209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd <br /> Company Name: <br /> SEP/T.�AGE CLEANER'S REPORT <br /> ��C �";� ^ f�^ � <br /> C � Report for the onth of: J11,1/1/ yearv/ <br /> Company Address:, -� J�%�r�� �L., �' <br /> Street Address city Signature: <br /> Zip Code <br /> All information submitted must be com fete, accurate, and le ible <br /> DATE NAME OF BUSINESS OR <br /> PUMPED PROPERTY OWNER ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAL <br /> PLEASE INCLUDE STREET 11DIRECTION STREET NAME AND CITY PUMPED GREASETRAP -� NAME FA TREATMENT <br /> C CHEMICAL FACILITY <br /> 72 AW Ci ���t�ol/ <br /> cit �r <br /> City. I/ <br /> fLi�L �!� lrit/r4-i�/(Lv� �L/ <br /> �/ r t / <br /> p at � � <br /> S lS L orZ p D J�' �itJ� �j✓p�7��y4o'+/ Cit � ✓-�lJ t c c <br /> '&4(,4111 Ci <br /> �L fo11p Lvq %t&M � A h/�¢G cit IJ <br /> J i <br /> ��✓/�v.S ll�g � G1/���N Gt/ 1 � l l <br /> 9 cit <br /> Cit <br /> Ci <br /> 41 <br /> Cit / <br /> / <br /> Cit <br /> l Cit <br /> Cit <br /> P//2 !i✓G G 8 S. /�?i(/C" c cit <br /> EHD 42-04 Page I Of S <br /> 12/27/13 <br /> SEPTAGE CLEANERS REPORT <br />