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Q�441ry ° SAN.JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this forrn 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 /> 59C SEPTAGE CLEANER'S REPORT <br /> Company Name: Report for t m nth of year,Ry/(l <br /> Company Address: 1136z) zLs - �Jr%. ��� 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 /> �u/ll cit al <br /> L� o�6Id GtJ �~ �/Z cit r� ,< < <br /> City <br /> I a A l? WlrdAAAL l Cit <br /> 46 / Cit <br /> rf/f2d/ )V9'mrrl Gmle- cit <br /> //� e2/55 w/W10 HLC-x F0;s /2Cit <br /> dI0-LOs /� %�� �'�/'-";'Vz Cit <br /> 01UP A) P3 NST, Awia4tz Cit <br /> AX-Dcw1ktksGr/ Cit i r 2 ZVGi= <br /> 0 C^)X W Cit <br /> Cit <br /> /� <br /> city <br /> R` / / / �if Cit <br /> City <br /> (/V✓NWS�/ v 0 l✓S /✓ Cit <br /> Cit <br /> Page }_of <br /> EHD 42-04 SEPTAGE CLEANERS REPORT <br /> 12/27/13 <br />