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QpgHlry <br /> SAN JOAQUIN COUNTY <br /> L HEALTH EALTH DEPARTMENT <br /> %`• �� Return this form by the <br /> 1868 East Idazelton Avenue, Stockton, CA 95205-6232 12th 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: o ylI��l �1�ii/�fG/!/��i >� Cls , 112 eJDu 0i17_ /T�. Report for the m h of: .J(�� ' year <br /> Company Address: /�.3� `lr�'C /3C, , �� ��/� ��. �v��3C� Signature: <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 <br /> PUMPED PROPERTY OWNER GREASE TRAP NAME OF TREATMENT <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY PUMPED (C) CHEMICAL FACILITY <br /> /v SS Cit zc <br /> C ity Uv <br /> r /9z° %IU 8 fid! Z-� city <br /> 2 32 nWM1 �Uo� Cit <br /> �f Atf ��e%%Z' 9�/�. City CWd <br /> d0 AUDdf 6. ii k4e-t/l�i Cit I <br /> Z <br /> Cit <br /> ! 'JU,, Sly%/I�C cit <br /> > � � Al- OA'l SdnJ Cit <br /> l ' 3av-s w > W,,61 c Cit , i 1 S? ) t t/ <br /> Q GU. e y zj�je- Cit > <br /> Cit <br /> City aura S 1/0C'9-- <br /> L 1 J S City r , / <br /> h1i nJl Cit ! 1A !1x <br /> E jw <br /> City <br /> Page _of $— <br /> EHD 42-04 <br /> 12/27/13 SEPTAGE CLEANERS REPORT <br />