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r4ulry' SAN JOAQUIN COUNTY <br /> 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 /> �ttsa�` <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: &Vqo'�m Q Report for the nth of: Ls year <br /> Company Address: 13_6?1(/L /J ��I &5g. 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 /> /�=/�/ ,✓ 1 (�G /rl v� > c�S Cit Ov0 i/ DG <br /> l � � fir// o1/rh/�d>` �� /i✓U� Cit U i i <br /> City t L c( <br /> �r��Y/�� Cit <br /> G/ <br /> v 7 / U/Yv' InIO J ?'7 j �/V W j% Cit UlJ(J l 1 <br /> 6-10 Cit S1—Loek A) <br /> %p ' •�ay3 1�/ nin5n � Cit <br /> M00 U r 909J 16TX10-4 1_16✓, /1111G�/,t�� city t 6 <br /> 4'va rh4 A4v,4 q17 City id <br /> /.3 3 a?,,flJ ,G/f/ �/� k? Z Cit Z 1 /�D�J ?. r <br /> /�i0[�� (O (/(/ C �✓' Cit , -"roe) <br /> / &1 a Nd' l , 6fdAI City it 1150)') r a 1 <br /> /G;7 ✓nir/�I�,G_`�'C,r9o% Cit / ,�-UffJ r t <br /> �'7a WD9/�'/m L01 /n�X''✓/� Cit <br /> Cityzz <br /> t t/ <br /> 5✓ /F 4)/ a I_/ 2 91/��n/I Jam}y�t/�i 1 s 9A)fir/ cit ��m/ <br /> V(// e 1'9V s�J� s'l�o/t//�/ /J`W -2'f Cit <br /> Page ofd <br /> EHD 42-04 SEPTAGE CLEANERS REPORT <br /> 12/27/13 <br />