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�0.�.cra roti SAN JOAQUIN COUNTY <br /> r 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'SREPORT <br /> Company Name: /!�l 6) (�8 � �� / (.eJ- Report fort onth ooff:� UC����� year <br /> Company Address:/ D �C��r ��-. /L�i/ll2 , Signature: <br /> Street Address City Zip Code <br /> All information submitted must be complete, 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 (C') GREASETRAP FACILITY <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY (C) CHEMICAL <br /> � a A76- 1 4:�3zl- city � C/C <br /> cit <br /> city Sad <br /> Cit <br /> City IMv <br /> a cit <br /> azl S lil/ <br /> e- Cit / — <br /> �lQ,Jvi .;23 Cit <br /> AYS4(- QS �/� (/L cit <br /> .� GfyOVi� cit <br /> r/q ` /f,' /o Cit <br /> � cit eJ <br /> 4 ,,4 00 <br /> 170dnl- ew1w ACity % t 0 <br /> l' s a3 �l'�1v� cit / /e�� ;I ,I <br /> city <br /> AJ 12V32 All) A� I �Z 12r W cit <br /> City <br /> Page 3 of <br /> EHD 42-04 SEPTAGE CLEANERS REPORT <br /> 12/27/13 <br />