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SAN JOAQUIN COUNTY <br /> bra-•.6� <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 /> SEPTAGE CLEANER'S REPORT <br /> Company Name: o! Report for the month of: n�year--;)G/ <br /> Company Address: 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 /> Cit <br /> cit <br /> O�U alt l /U�✓ e A' /V4 City <br /> dryfl-/GC S.� US 1/II�S%/ ✓/� Ii✓2 Cit <br /> Cit <br /> l Srn. i�iJ�Of L S C l�� x211, cit �l /JTirJ �v��,al Z,-'-L/�' <br /> 5'- �' �r✓i9 G111 /�'�S /Y4,2�}'Gr1.Cs /L/Z cit <br /> chtl/ 33.�5� on�2 G�✓E cit / <br /> cit <br /> rnt7 cit <br /> Flo 4AIJE cit ddb <br /> 99-A ' Cit <br /> ,no city X--5W <br /> / `,✓ ��� liU., ���s itT cit /6w r ,y/ <br /> a 2,Z 7W. /Y�'�'�LT�/Y�✓� City Z �V !/f�cl✓� �U�Yti <br /> L 'j✓�/l ��✓S � i�'l C Z"Owe- cit <br /> j?2 cl�vr✓>NCOl /v 3 T AV i AovG,ii cit <br /> Page of_Z <br /> EHD 42-04 SEPTAGE CLEANERS REPORT <br /> 12/27/13 <br />