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RECEIVED <br /> Arautry SAN JOAQUIN COUNTY AUG 0 6 2014 <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6 IRO TALHEALTH 12t" of each month <br /> t �, �;;*P Telephone: (209) 468-3420 Fax:(209)464-0138 Web:www.sjggy �RVICES <br /> Q SEPTAGE CLEANER'S REPORT <br /> Company Name: 5r 1 (/L" //j�C- Report fort onth of: 7 ,I, year/ <br /> Company Address: /��5� %���f� L- ''• L�J���/� (j/f � 3d 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 /> City C <br /> o?cZ h/ fi G (l2 do l t c_ 1h lei 6q cit c' /'/1 D 6� r t < ! t <br /> U City. <br /> ! !!!C� 05 /� /rd��'L� 1,� /l✓V �� city 4/2�2 Cj9 c l <br /> LS— J S lNG�1 /Vi/ � Cit <br /> Cit <br /> Cit <br /> 64 o Cit !� 14 <br /> Cit <br /> cit ! vv <br /> cit <br /> a/ o�(�aZQQ�� Ch4U4446 4'q 1Z cit <br /> Cit <br /> //D G� � ��� ✓� Cit r� <br /> � O1�-,/U/ 174" �( � City <br /> U� J/�3D✓G6 �r. v /j/� 7&14jZ aLi- Cit <br /> Cit <br /> Page Of <br /> EHD 42-04 SEPTAGE CLEANERS REPORT <br /> 12/27/13 <br />