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SAN JOAQUIN COUNTY <br /> a! ENVIRONMENTAL HEALTH DEPARTMENT Return this.form by the <br /> ti, `• 1868East Hazelton Avenue, Stocldon,CA 95205-6232 12tH of'each month <br /> Telephone:(209)'468-3420 Fax:(209)464-0138 Web:;www.Sjgov.orglehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: Report for the month of: t�v J <br /> Company Address: - ��— <br /> p year-4� <br /> Signature: <br /> Street Address C <br /> Cid' Zip Code <br /> All information submltfed must-be com lets accurate and le lble <br /> DATE NAMOF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLON'S IRIs1D-°1DE � NAME OF TREATMENT. <br /> PUMPED PROPERTY OWNER PUMPED GI GREASE TRAP FACILITY <br /> ' I PLEASE INCLUDE STREET S DIRECTION STREET AME AND C1.TY C AL <br /> c ty <br /> Z Lo@v ��l]d �61/iT /�i1�1�[t�/9 city <br /> 11V1 Al 5 a t1 C`�9T1 J L //7// !lJ l c • % SIJJ <br /> C- "i/ i 9�L �155�"Jl/, �� li e✓ <br /> five. cit U� <br /> Q .• <br /> V, cit 5/Jc� <br /> e/L A-/ Ws ca dd <br /> �r-12 2 44 city <br /> 5�eh A/ 1 F%i' 4-1cte <br /> � o7t/J <br /> city <br /> ( /L - .�'� lI'I / �' T m 2 cl <br /> T R/!JDf CK t <br /> l ynrwT J 0,;k D S' ei arJ� <br /> Cl 2/�mEiJ (Ca5 a /� inC Cl l <br /> D /7(�/ Uh 'i CI <br /> cit <br /> Cl <br /> ` <br /> _ //J cit <br /> Page .. of � <br /> EHf)42-0.4 ' <br /> 12/27/13 <br /> SEPTAGE CLEANERS REPORT <br />