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4111+1 RECEIVED <br /> JUL 11 2014 SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this fond by the <br /> 1868 East Hazelton Avenue, Stockton,CA 95205-6232 <br /> (D Tele hone: 2 (2t''of each month <br /> °��a�' VIRONMENTALHEALTH A ( 09) 468-3420 Fax:4209)464-0138 Web:www.sjgov.org/ehd <br /> o <br /> PERMIT/SERVICES, <br /> SEPTAGE CL_EANER'$ REPORT <br /> Company Name: pr a v <br /> /S Report for the mo th of: &I <br /> y �• ' t �.Iz��xCyearCompany Address: ?O! Signature:Street AddtNss 7 � <br /> Zip Cude <br /> All information submitted must be complete, accurate, and legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS D0Np GALLONS (R) RESIDEMML <br /> PUMPED PROPERTYOWNER {G) GREASETRAP NAME OF TREATMENT <br /> t� PLEASE INCL-UDE STREET X, DIRECTION, STREET NAME AND CITY PUMPED C SAC[LITY <br /> 9 S S` { CHEM1llCRL <br /> Z <br /> H <br /> y C L r� ✓� c , g <br /> / y� y sC v C <br /> J L(u Lti/'! Ci i' 4 C-/ 3/ <br /> 11] _ <br /> / v tL /� // a/ C f city <br /> a ��� C rc4� �.- �y `(�- S //ofh Ca <br /> o <br /> 0 <br /> ---------- - ----------- - -.._.. __--- cit.... _ � <br /> YA- <br /> city <br /> � d- <br /> N Cil <br /> V <br /> C9 _ <br /> v f <br /> L0 CI d <br /> Li l <br /> O� <br /> CD Cit � <br /> C'4 <br /> 1 <br /> s Cll <br /> .� City <br /> Cil nI <br /> E <br /> V � <br /> ,� CI <br /> CD _ <br /> `1 Page of <br /> EHD 42-D4 a, <br /> N <br /> 1227/13 SEPTAGE CLEANERS REPORT m <br /> CD � <br /> E%% 0 0 <br />