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Q�,44Iho <br /> SAN JOAQUIN COUNTY <br /> '` ••"< ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> + <br /> 1868 East Idazelton Avenue, Stockton, CA 95205-6232 12t" of each month <br /> " ; �•d�:�~' Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: �E Ll l�J <br /> -"—� Report for th nth of: �4a1AUA�l year - Ul <br /> Company Address: �j��1�t �•-� � r" <br /> f-� Signature: <br /> Street Address � City ` Zip Code e Si gt <br /> All information submitted must be complete. accurate, and legible <br /> DATE NAME BUSINESS OR ADDRESS WHERE WOR (R) RESIDENTIAL <br /> PUMPED PROPERTY OWNER K WAS DONE GALLONS GREASE TRAP NAME OF TREATMENT <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY PUMPED FACILITY <br /> � C) CHEMICAL <br /> C ity / 5 Gv'C <br /> citv '� UL) )� t 1 <br /> SM /.tJ Cit y�o� <br /> Cit <br /> y Sao <br /> �IfxtCit <br /> J /Vo koe;d /'o <br /> City � <br /> Cit J <br /> cityz <br /> cit 1 <br /> cit <br /> Cit <br /> 5P �✓ ` .a �U &P-57- cit <br /> SLS <br /> Cit <br /> City <br /> Cit ��L <br /> Cit <br /> Page LZ of <br /> EHD 42-04 <br /> 12/27/13 SEPTAGE CLEANERS REPORT <br />