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�quth' SAN JOAQUIN COUNTY <br /> z ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 12th of each month <br /> . *P Telephone: (209) 468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd <br /> 'e i�i5•a�`: <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: Report for th nth of: year D/ <br /> Company Address:J/Jaf/rJI � �7 �� �.r�� ) 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 (G) GREASETRAP FACILITY <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY (C) CHEMICAL <br /> 1211-1 C:2a <br /> Cit <br /> a a /a3� lyy��Y�v�s/ iA%� City <br /> `� ll 7.�, AlN• //WiA lY (� Cit <br /> 0^ Cit <br /> f Ali oq Cit '51-4)C,f�j L)L t � <br /> "� i�3S� Tia✓ �c ��nn�_`u/�rl Cit <br /> Cit <br /> Cit I �'()G <br /> �! E' Cit <br /> 0 <br /> 7SC, 'C e Cit <br /> cit l <br /> city <br /> /) aj A a-2"7,;LW- //l .I Z9WZ City /k ( f <br /> _ Cit <br /> at � � ��lJv � � <br /> Page —9 of <br /> EHD 42-04 SEPTAGE CLEANERS REPORT <br /> 12/27/13 <br />