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N <br /> C i <br /> RECc:IVED <br /> < , SAN JoAc�ulN COUNTY <br /> > nr ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the � <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 12th of each month <br /> SEN o 5 L014 Telephone:(209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd <br /> o <br /> L I/;; i5�' <br /> ENViRONM�TqL EALi i SEPTAGE CLEANER'S DEPORT <br /> PE <br /> Company Name: 1 f 1 ...° Ei%° Report far the month of: j�lyearf�� <br /> Company Adeiress: .f ; t ���<�� 2 <br /> ' ��e;' ` Signature: <br /> � <br /> p y Street Address f City I Zip Coda <br /> All information submitted must be coin fete, accurate; and legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAL NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED (G) GREASE TRAP FACILITY <br /> PLEASE INCLUDE Si RiC�ET N, DIRECTION, STREET NAME AND CITY O CHEMICAL <br /> 91;o- ( �1 A ,g G{ °� i ccM L . c city P t• vacL �i.y, <br /> cit - Pr" • f 10 Tkdaj <br /> l' .r° 40-'2& Oki b,V1 i?dL.a+k citX n ?4t'.G�XA0( <br /> � <br /> 1�;�1P1� d City <br /> p t t 01-0'!9 'r yv 7 C C Qom+ `i C/} f I Ci Y <br /> '2 ��1et .c+ 3(a.-� _._i— G� +-�i1-r�. d �. ci <br /> hr13, city <br /> o 1 4 e - <br /> LL7kL r�rr',� Ci 1-&^4-A i <br /> Ci 1 G'L- � ' To <br /> w <br /> Cit rl(u: D� YC U � z <br /> 51 <br /> Lfl <br /> city_ cr <br /> m <br /> city <br /> �t- <br /> city <br /> city <br /> cit <br /> Q <br /> Ci c/D <br /> Cit <br /> City <br /> O <br /> Cl) <br /> m a� <br /> EHD 42-04 SEPTAGE CLEANERS REPORT v <br /> 10/4/07 a <br /> - <br /> H <br />