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A�,441'Y, o <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 12t" of each month <br /> +�; �•��;� Telephone: (209)468-3420 Fax: (209)464-0138 Web:www.sigov.org/ehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: - <br /> Report for the month of:%� Glu year <br /> L m / <br /> Company Address: Signature <br /> Street Address : <br /> City Zip Code v <br /> All information submitted must be complete, accurate, and legible <br /> FD,AT7ENAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAL <br /> PROPERTY OWNER GREASE TRAP NAME OF TREATMENT <br /> PLEASE INCLUDE STREET # DIRECTION, STREET NAME AND CITY PUMPED C FACILITY <br /> / ) CHEMICAL l ] J L <br /> 9 9Aetilfm6// ' /� cit �C.��A7 J✓ % 5(/U <br /> G,UL )"V U /7>M�1/✓vC1/�> ,(� %d cit ll 521 t I <br /> CE )VAT 17 Ci r%/l/ fGljctL g & city 'f&¢G/e <br /> Ae�26- �Cl�i�d�1�✓'l�S�' <br /> /9V l Ct40t� ',ln 1-75A) 1/i l /j Cit <br /> (IMN WhVis ' v W SO4,t lTe kU19V <br /> Al .3V3 0 Alii�i 74ilLetl Be,. Cit / t l <br /> U a y �✓ L12v -Di t <br /> City 7VUJ It t <br /> 1 -7 &d7ci2 xz"�'-A/ev a 9 9t� (9�✓i 2`/i✓ ,9-0 Cit sv� , <br /> a s7�1 city 50I , <br /> l/I/ r✓� _'f 35` ,Zcf% L� /L( Cit <br /> Cit <br /> t,J *2770 /I/i9t LFG R t�4fl Cit / S-0t t t <br /> Cit <br /> /04i ll'o Z69&D a�li� /V r.� v Cit <br /> citygewr <br /> cit <br /> Cit <br /> Page of <br /> EHD 42-04 <br /> 12/27/13 SEPTAGE CLEANERS REPORT <br />