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0�4uIry SAN JOAQUIN COUNTY <br /> e.�ri-Cam <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 12th of each month <br /> • ;•.. ;rP Telephone:(209) 468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: `x ' iO7b n1C Report for the onth of: 6 year <br /> Company Address: ��3C' Signature: d G�d� <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 (G) GREASE TRAP FACILITY <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY (C) CHEMICAL <br /> ca a! /�/pdD / k it <br /> �J 'm (- l.(��Se i= City I U�v ` <br /> 6 01h U,09 M&;'k. (n�..SQf{u C! /Q1) City <br /> a l i a Cit i wv I l t , <br /> o - 7 8C) W-S c'G P-m-O Cit <br /> Cit <br /> cit <br /> Cit <br /> Cit <br /> cit <br /> C it <br /> Cit <br /> Cit <br /> City <br /> Cit <br /> 177- <br /> Cit <br /> Page of <br /> EHD 42-04 SEPTAGE CLEANERS REPORT <br /> 12/27/13 <br />