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r ECEIVED <br /> 0.i4u1� SAN JOAQUIN COUNTY DEC d 9 2016 <br /> ENVIRONMENTAL HEALTH DEPARTMENT N,VIR Return this form by the <br /> " �•> Tele 1868 East Hazelton Avenue,)Stockton, CA 95205-6232 nF ��1 CES H12t1' of each month <br /> phone: (209)468-3420 Fax: 209 464-0138 Web:www.sjgov.org/ehd M T/`E <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: �� ���� /./11� 1, A� <br /> Report for the nth of:/U year a0/ <br /> Company Address: <br /> 96- Signature: C1/��iC/ <br /> Street Address City Zip Code <br /> All information submitted must be com lete, accurate, and legible <br /> DATE NAME BUSINESS OR ADDRESS WHERE WORK WAS DtR) <br /> PUMPED PROPERTY OWNER ONE GALLONS RESIDENTIAL <br /> cREASETRAP NAME OF TREATMENT <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY PUMPED C FACILITY <br /> CHEMICAL <br /> Cit <br /> -A✓-6u-mfo> / /8ayo <br /> cit <br /> City. <br /> �'7 Gl ill G/ac�C .57 r'!S. �t i� cit <br /> �'� C'fC E�tit s` Gl 7a5 Cit 1/ r / <br /> .qv <br /> & . <br /> Cit <br /> Cit <br /> /a,3 D lrV L <br /> oil Cit <br /> �po GU. Cit <br /> �t c/ <br /> �'I�J�✓�L v 1, �L// T /�� � Cit <br /> - Y cit <br /> / Cit <br /> G !/✓ �o <br /> 23 ,fob i 01190 um Lilt r' City P a5' <br /> ii <br /> 30 pit <br /> 1/ II <br /> Page��of <br /> EHD 42-04 <br /> 12/27/13 SEPTAGE CLEANERS REPORT <br />