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a4`�ultt, <br /> z; 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 /> `+r•.�•��:�} Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: Report forth month of� year D/ <br /> Company Address: �3,�(, �/"''��� �. �� • G��,, <br /> Street Address ) Signature: <br /> city Zip Code <br /> All information submitted must be complete, accurate, and legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAL <br /> PUMPED PROPERTY OWNER GREASETRAP NAME OF TREATMENT <br /> PLEASE INCLUDE STREET # DIRECTION, STREET NAME AND CITY PUMPED C CHEMICAL4466 FACILITY <br /> '/ ci / 116 ) <br /> /Ll VZ� 7V3 / 1 SSI wi-1G / City. j <br /> lc c/ <br /> 700 /`moi/i/ ! > cit 1 city <br /> A. <br /> J vc <br /> City <br /> 'IV 1 t" d Ci <br /> It <br /> / ll- .v✓l, a --'r F city IL <br /> A/-�y/uy�cl0 ,�-r ✓/�1��G i4✓��✓vt� cit � ' `7 it ! / <br /> //1 � 7 I .�� J Cit <br /> % l / -7,30 <br /> Jf iy/iTE �h/�, i <br /> Cit 1 \ ( I <br /> T02i Td aS� /Y1r9�7 <br /> cityvU i I <br /> �3i 9 rJ T city I/ <br /> c� rn n 10 s Ss- - i /fit? SR t!�c/I-- <br /> s a/P 7v > Cit / add I t 1 <br /> ICA IS .>2 �;—3.56 > -7 Y <br /> Cit <br /> Cit / <br /> Page _ of <br /> EHD 42-04 <br /> 12/27/13 <br /> SEPTAGE CLEANERS REPORT <br />