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SAN JOAQUIN COUNTY <br /> i 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'S REPORT <br /> Company Name: )• 'l Report for the th of:Si n year o?J <br /> Company Address: ��J��� %,E ^ C/ 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 ST/REET #, DIRECTION, STREET NAME AND CITY (C) CHEMICAL <br /> d'/_ <br /> (25i00 - r; YC HU C ity <br /> C qty 1 U t c <br /> City <br /> >I l <br /> 3 217 `� 8G City I <br /> �I AT cit <br /> r WA) /9 W'/X-Y aL7,_e 121 Cit <br /> •S( 30dAiR_ CFS lgo,4-� C ity <br /> tVigib2 F,2 010-5- 02 5 Cit <br /> C l �� / SIT % cit I I -2-57- <br /> City <br /> City <br /> City <br /> City <br /> City <br /> Ct <br /> Cit <br /> Page of-� <br /> EHD 42-04 SEPTAGE CLEANERS REPORT <br /> 12/27/13 <br />