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Qr,4Blty <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.sjgov.org/ehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: 1� awl t,jy/0/14-1 <br /> Company Address: Report for the onth of: yearyl� <br /> ,�..>����� <br /> Signature: �. <br /> Street Address City Zip Code <br /> All information submitted must be complete, accurate, and le ible <br /> DATE NAME BUSINESS OR ADDRESS WHERE WORK W (R) RESIDENTIAL <br /> PUMPED PROPERTY OWNER AS DONE GALLONS G) CREASE TRAP NAME OF TREATMENT <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY PUMPED FACILITY <br /> CHEMICAL <br /> �Dv7t/ C o`�0 Cit <br /> F- <br /> m�vv S 3/V3 i A)1Ur1G' CityI t /S7/� I- 1 r <br /> /9290 Fi �?yv d1C'! /Vf� City. 1 r ) t I <br /> 6' � �n�✓� �u Cit t r <br /> cit <br /> 2 5'019'IA�C'fy L-9�ri/ i <br /> _ at <br /> cit <br /> �L 10 ),OM <br /> —/W t� cit J I <br /> Lv U <br /> l ' <br /> Cit fl ! / 1j <br /> D�✓/ D S l U!J G d/17 Cit 4lIF�S' <br /> l /`J C l r cit <br /> / C r <br /> OILZ-1191 i cit / <br /> G � City I 1 t it <br /> f / <br /> cit <br /> Page ofd_ <br /> EHD 42-04 <br /> 12/27/13 <br /> SEPTAGE CLEANERS REPORT <br />