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,Hurn SAN.JOAQUIN COUNTY <br /> ?01e.wr-�'�oti <br /> r_ ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 12tt' of each month <br /> Telephone: (209) 468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd <br /> �nSEPTAGE CLEANER'S REPORT <br /> Company Name: Irl pu'vm'4'�iReport for the th of: year <br /> Company Address: A5"57VC, 1Y/&Z COL.. 9.5—e Signature: <br /> Street Address City IZip 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 /> 23,R3 W9iMin G 4,Wli-; cityC'tC/v9t/ �D i�IJD <br /> city <br /> Sril0 <S '7900 G 4V City / c <br /> `7 1 -w- wr?,'V.1 � cit dJ 1 c l l <br /> /0- " 196T05 Cit <br /> t� 1 o E A � Cit 1 7� �l�U t ► <br /> c/ M'FOOA✓/ 3V5d Al2�01 City l( <br /> Ov ►, c� <br /> OR <br /> 6-7113P C J ld `A Aft Cit <br /> d r r GC.. Cit <br /> ,� r k� Cit <br /> / / r) •Sri/ L r�/vf/,)W Cit <br /> �f 49 W/9,, 0QC��� /ZU,/Lo cit � L� <br /> 3/02 tr1 A))Aw Cit I [ 7 <br /> Cit // <br /> 00 2mT/'} ,Z RLPIW City / •1� r I <br /> Cit <br /> Cit <br /> Page of <br /> EHD 42-04 SEPTAGE CLEANERS REPORT <br /> 12/27/13 <br />