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Q�aulry ` SAN JOAQUIN COUNTY <br /> r' ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Return this form by the <br /> tH <br /> 12of each month <br /> +.....c� Telephone: (209) 468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: Report for the month of:,/4A earo2 <br /> Y <br /> Company Address:zo--5y / � �� a ��� G 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 G _ GREASE TRAP NAME OF TREATMENT <br /> PLEASE INCLUDE STREET #, DIRECTION STREET NAME AND CITY PUMPED (CI CHEMICAL FACILITY <br /> >�'� dzv l 8/ /� &AM-6i' 1-90pyl cit GC>Di i4 <br /> L lad/10 Zo �, l D 'F�?/^�. Cit /,511 <br /> �� ,E f c- -/� Cit <br /> y <br /> U�l &n IM2? 2 1 - /Az- cit Ovc1 <br /> 0 73 s7 4 .S-1Ilf� Cit <br /> Cit D <br /> Cit $�v <br /> Cit <br /> City 701-V a� <br /> z 1 <br /> d GI/fir/11Cityi a- d <br /> � Cit � ( <br /> 1V ( i <br /> City <br /> Cit �I <br /> Cit l( J <br /> JOS U �2 City A t( <br /> IVA Cit ( / <br /> Cit <br /> Page of <br /> EHD 42-04 <br /> 12/27/13 SEPTAGE CLEANERS REPORT <br />