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Qp4�t I>r k VE® <br /> r ? SAN JOAQUIN COUNTY <br /> ' 2016 <br /> _ ENVIRONMENTAL HEALTH DEPARTMENT <br /> •`'�/ aa�`}. <br /> Telephone: 8 E st Hazelton 420 Ave(209) 464-0138 Web: <br /> 95205-6232'1 2^n E,JTA�N Return this form by the <br /> L.: <br /> Web,www.sjgov.org/ehd IL SLTH 12th of each month <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: �IYJ �!Ul��i�/G �. <br /> Company Address: R14 Report for the month of:�-�"B/(� <br /> Street Address City � (= Signature: � �—`���' <br /> 'yllU <br /> year o'32/ <br /> All information submitted must be complete, accurate, and le ible Zip Code <br /> DATE NAME OF BUSINESS OR <br /> PUMPED PROPERTY OWNER ADDRESS WHERE WORK WAS DONE R <br /> ( ) <br /> GALLONS RESIDENTIAL <br /> a PLEASE INCLUDE STREET # DIRECTION, STREET NAME AND CITY PUMPED NAME OF TREATMENT <br /> ) GREASE TRAP <br /> �iN7V-tJlf//7J�/T Gqy (J C FACILITY <br /> CHEMICAL <br /> ��✓ �v� Cit <br /> 00�M'LrP6 /gayd12 <br /> '¢ R C�914nCl�S /YJ i A0 c v �S. Iy2¢iUj GL 2v City <br /> cit 2 <br /> �/ C U�i /fOTr,t m /(>9 L127i SG�/SOC Divi y50J <br /> qCit <br /> QQhJ�Z L0 / 0 Ll/�J T �/C /� ✓V' , <br /> ii►-C,[/lG;�j� �-NC �'�(� f!/�•flL-Tjl�lY1�V 1�✓/� cit <br /> Cit <br /> �( �l�Cl'�Y`V L�Jt�Ii� Cit A /� <br /> �� r ( ( l <br /> �v Dui mune rr„z S`G(/�1 i fZ TjU <br /> cit <br /> 'd64 / fvJ ii✓�C his �.1�r�i �h/� � i � � l/ � <br /> it <br /> CC <br /> !a✓� Uo �✓vrLTh' �z9iiv S'iRi i ¢ J <br /> Cit <br /> %O KoBis►l 973 A�iz <br /> ! cit%� Ne/ �9/lF� S�yru p 4Y� 'ZR y7s__ <br /> a city // dd-D <br /> _ ;. <br /> �� �l�P/C r.� l jji✓GiL 703 r Cldd(7 <br /> �T bSir,�✓/i�f'' <br /> Cit <br /> EHD 42-04 Page of <br /> 12/27/13 <br /> SEPTAGE CLEANERS REPORT <br />