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z SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232..... 12tH of each month <br /> `' � Telephone:(209) 468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: ��v SSC�um,o��v� (In <br /> ��.3-��%C�/� �• ��/fl��, �- �.S ��.a� Report for the month of i-2_-1/-i �—/G <br /> yearCom an Address. n- cJ <br /> Signature: � <br /> Street Address City Zip Code <br /> All information submitted must be com tete accurate, and legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS #(R RESID LPUMPED PROPERTY OWNER GREASE TRAP,.I NAME OF TREATMENT <br /> PLEASE INCLUDE STREET # DIRECTION, STREET NAME AND CITY PUMPED FACILITY <br /> ! CHEMICAL <br /> cit <br /> %GOAj � c cit <br /> City <br /> vV/�i/If SG�/✓�r L s�/J�� &bvj'21 — 4'h l Cit <br /> �t 11-7 J C at 21) t <br /> c,1SCitv <br /> J i161 i Jt/ �S` �Ell) Cit �/ J <br /> cit / � t � <br /> cit <br /> �- ZK? s _ o s <br /> Cit <br /> i,Al Co fi56 <br /> Cit c ' <br /> is / V__rA, <br /> �/yl/27/7/'l ciJyv� cit � l I <br /> /� // <br /> C3 C Cit 1u <br /> Cit <br /> X033 s4ww - i <br /> t�'it+nr city <br /> ���l�f%li;/16 /YIg X j � � � /✓I�/( �i9v1/� cit AvA r� <br /> City <br /> Page -of y <br /> EHD 42-U4 <br /> 12/27/13 SEPTAGE CLEANERS REPORT <br />