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SAN.JOAQUIN COUNTY <br /> z' •m <br /> ' - ENVIRONMENTAL HEALTH DEPARTMENT E Return this form by the <br /> : 1868 East Hazelton Avenue, Stockton, CA 95205-6232 APR 12th of each month <br /> Telephone:(209) 468-3420 Fax: (209)464-0138 Web:www.sjgov�q�g[�ehd 2016 <br /> SEPTAGE CLEANER'S REPORT PE��SER�HILI- <br /> tj <br /> Company Name: ` �' SES <br /> Report for theufie�th of:� C yearo70/ <br /> Company Address; , <br /> Street Addresi � ,4 <br /> Signature: J ! <br /> Ci 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 /> 3d ,i� a� uT s��� Ci �o�; l�cJ <br /> tViAli 16 e&V �5d5!/I`J�7-6+12 Cit <br /> City <br /> 51d t'I*1 . cit � <br /> a 3 i c/1�nii"rc cit <br /> W/ Cit <br /> /" . �/1�� U/V U Cit ) 1 ! <br /> b vv T dW✓� - cit <br /> 2 9 75— S/ <br /> City <br /> /V city P <br /> cit <br /> A/, <br /> Cit <br /> cit r l- <br /> cit <br /> Po 110 /r <br /> City <br /> ,av cit l( <br /> �1 <br /> �S 31d 4�a'/'?f �,G G� cit I / <br /> Page_--?, of <br /> EHD 42-04 <br /> 12/27/13 SEPTAGE CLEANERS REPORT <br />