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SAN JOAQUIN COUNTY <br /> z 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: �� C 010- Report fort nth of: year <br /> Company Address: ��i / 1' Signature: <br /> Street Address city I 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 /> h) PLEASE I,NNCCQLUUDE STREET #, DIRECTION, STREET <br /> S/NAME AND CITY //60 (C) CHEMICAL <br /> City <br /> ,ql-4 ZZ I A4; /-/*L, City !! 02 <br /> 32 V3 Cit <br /> ����✓ /Oyu / �9�!/E Cit <br /> Cit <br /> / v L t 4M�f 4Xiy,6L Cit <br /> cit <br /> ' ,3 A'/ /t✓!yI/nli,-z 4. 'o/ cit <br /> � /L% /99l1 City /! <br /> /C% G Cit <br /> R 3 ��-,r,/,�/� �1 Cit <br /> 07 /f!7`J Ot1� Cit <br /> City c/ <br /> �4 & rhvr� LMA�)WOM1 city <br /> a72 / �� <br /> Alll <br /> G cit P <br /> /dn /f C'zav/ �-7- Cit 1 ` / SvU <br /> Page .3 of <br /> EHD 42-04 SEPTAGE CLEANERS REPORT <br /> 12/27/13 <br />