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ap4Itlly <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Return this form by the <br /> Telephone: (209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd 12tb of each month <br /> Company Name: <br /> SEPTAGE CLEANER'S REPORT <br /> • <br /> Company Address: ZI—51-?6)L Report for the nth of: year a <br /> Street Address City � Signature: <br /> Zip Code <br /> All information submitted must be complete, 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 #, DIRECTION, STREET NAMEPUMPED G) GREASETRAP NAME OF TREATMENT <br /> /a �� r/W✓C �� L�,�"�� � ��!D AND <br /> NND CITY CHEMICAL FACILITY <br /> Fc> Cit �- <br /> -A (--Dui 4 1 Wj W. <br /> cit /5� i r111� OD/dF�S <br /> City <br /> 1 1 <br /> Cit <br /> /C <br /> City �• l: � <br /> :2 � & <br /> Cit <br /> /W" G • ��d Lf/Ry r��lGc� /C PJ/� Cit <br /> LOle) at <br /> 02 <br /> Cit i L/'w U <br /> G/G)Jl�• � �JU Gt/ L E A <br /> `A Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> City <br /> Cit <br /> Cit <br /> EHD 42-04 Page�_Of <br /> 12/27/13 <br /> SEPTAGE CLEA14ERS REPORT <br />