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APqultr ° SAN.JOAQUIN COUNTY <br /> } :o.cr-+-•.ate <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 12t" of each month <br /> .. a P Telephone: (209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: CGC l C Report for th onth of: �'�54/4 year <br /> Company Address: f� Air=jE2Q Iqt &. SSC% 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 /> ,� �' U'U 3/ / ��✓1�//i��— city <br /> City 1i 7l t <br /> /� city <br /> /7city <br /> n I / L1S� J I C! Cit <br /> City <br /> , 411 n Ala % Cit 7/ <br /> A /)-/ <br /> cit <br /> a 7-11 x/97 c5 Cit <br /> / v ^•//�/r /�/,� /_, /C Cit l / 1 ` t <br /> Ov� lN��/A,16,41�-,V4 F Cit %u!/U -c l t t� <br /> �C l e ,��� �C L.-ai _ Cit r z <br /> Cit L l <br /> '`��� <br /> i O� , !l�IYUI/ Cit <br /> o23a3 l4iS> r '1 1,9-A/Z City <br /> cit <br /> i <br /> Cit <br /> Page _of <br /> EHD 42-D4 SEPTAGE CLEANERS REPORT <br /> 12/27/13 <br />