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�guln. <br /> RECEIVED <br /> �O1e.c�-pati SAN.10AQUIN COUNTY <br /> r ` ENVIRONMENTAL HEALTH DEPARTMENTSEP 201 Return this form by the <br /> i 1868 East Hazelton Avenue, Stockton, CA 95205-6232 12t1' of each month <br /> •rt.. aP Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.o hONMENTALHEALTH <br /> PERMIT/SERVIC T <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: U: Report for the nth of:- 14 S year R0/ <br /> Company Address: //�Jr� // ifs �l � /1/��JGjJTjj �g_ ���3a Signature: �v /.,,- '/./ <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) GREPSE TRAP FACILITY <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY (C) CHEMICAL <br /> l3-� rvDUL .5L-Pq7 z) 6,0 city Aa <br /> cit // <br /> (Y1A)&j1t AW Lodi AA 9 O Gt6�I�'G1TGG`"'h-1 L%/G city A D v q v <br /> 17116 <br /> / <br /> city2()el.rf !� It L <br /> 17G/6W:144 I I Cit .2 <br /> &'4al� /UW /S?JS /V T O /drl/ A '` l$?J 4) <br /> City <br /> S,1n10-1LT1:iVV-r 6/0 9cit <br /> I ( Cit <br /> /! 1�.✓�LQ� o?f/V GC cit <br /> (° Or✓�9 CQ� D7 Cit 1 S t f l <br /> /9 '8 u ,6t fG/4/ 3 o 41/- v►/� Cit I/ <br /> ,R5 9 N 1)zWG > � Cit + , t <br /> / o&n/d►G &G(Aa#0 022 a y7S � r O SZI)11'7 2L city bAkInye"5z <br /> -A/- c 9e ' veli��' city I G/ <br /> city <br /> IImr cf" kr6y ` � city t/ <br /> )w&-ocrl/1w- 9-S Cit <br /> Page A of <br /> EHD 42-04 SEPTAGE CLEANERS REPORT <br /> 12/27/13 <br />