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SAN JO <br /> of AQUIN COUNTY <br /> N ENVIRONMENTAL HEALTH DEPARTMENT <br /> ' � {) 1868 East Hazelton A Return this form by the <br /> C • venue , Stockton , CA 95205-6232 1h <br /> ` . r �� Telephone : ( 209 ) 468 -3420 Fax: (209 ) 464 - 0138 Web : wwW . sjgov. org/ehd 12 of each month <br /> SEPTAGE CLEANER' S REPORT <br /> Company Name : <br /> Report for thAmnth of : �i.� RG year � a <br /> Company Address : � � /--� � l� -A Kc-Aj c1ez,J <br /> Street Address I Signature : �-* �- <br /> City Zip Code <br /> All information submitted must be com lete accurate and le ible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS <br /> PUMPED PROPERTY OWNER ( R) RESIDENTIAL NAME OF TREATMENT <br /> PLEASE INCLUDE STREET # , DIRECTION , STREET NAME AND CITY PUMPED ( G) GREASETRAP FACILITY <br /> LCL, CHEMICAL <br /> � bc. � Cit 6 / �f v d S 1�' � 1 <br /> �bc) � /tA o Ail w I Cit � v � o Q- U� TT <br /> o4 • fan �p INN .5'C� � r city Accitrtf vo 1300 <br /> cit L' <br /> rut w 6 ,50 / j W e Cit 1 ?'1 C) �Uv IL4S R <br /> Le <br /> d Ibor M, P `� & T o /l/ , ��w I`'INNCit <br /> � — � C s 6 C4, Nt H Cp 6 /U , Cit G O <br /> Cit <br /> City <br /> Cil <br /> Cit <br /> Cit <br /> Cil <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> City <br /> City <br /> SEPTAGE CLEANERS REPORT <br /> EHD 42 -04 <br /> 1014107 <br />