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RECEIVED <br /> MAY I S 2016 <br /> Q�aut� c SAN JOAQUIN COUNTY <br /> i ENVIRONMENTAL HEALTH DEPARTMENT HEAL]l% <br /> t'ERMIT/SERVICES Return this form by the <br /> 1868 East I-lazelton Avenue, Stockton, CA 95205-6232 12 of each month <br /> Telephone: (209) 468-3420 Fax:(209)464-0138 Web:www.sigov.org/ehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company , gwjpJG Report for the nth ofd /L!L year <br /> Company Address:/ �� �L. / ' 0,4-- �S� 3 v 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 IDENTIAL NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED ��'� GREASE TRAP- FACILITY <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY C CHEMICAL <br /> Cit G dL`' �Y�ID7� 6E <br /> at) deA/Ovrr:! (o .Sf)-t�9Rl•9a/ � cit /r ;gid. <br /> City % / �✓�v <br /> (11� /W Cit <br /> /✓W lcJ�` ll�C� D/�/iTt/ l/9 Cit <br /> city <br /> amu' Cit <br /> 0 W. Cit r <br /> ov :l v /l�t/r�Ck�n/��/�, _ L � Cit <br /> Z /J ✓V, / YA/ IW Cit / <br /> I-A�'Vz cit l/ / <br /> at <br /> ''//� .S �` ' !/�/�'I//L o3"/�f�a 7m ✓(/ /Wi� Cit <br /> ccS'Ou-2t- Cit <br /> Cit <br /> Cit <br /> Cit <br /> Pag6 of <br /> EHD 42-D4 <br /> 12/27/13 SEPTAGE CLEANERS REPORT <br />