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0.Raul'r' ° SAN JOAQUIN COUNTY <br /> r_ x ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 12t1' 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 6=191,Aje--) L01 Report foronth of: Jcr year <br /> Company Address: 12 z /L V �,. VTV/ 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 GREASE TRAP% FACILITY <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY (C) CHEMICAL <br /> �lj , / A(.-31? 1z 1 c2S,F/�/ili, �`�i//� cit �C� U� D� <br /> TC�d✓C t)(/ /Lrd,, i//✓ /�16;i cit <br /> 1172 . Alf";A city <br /> Cit <br /> �J �/ J Cit ���/ C� (�/i�,1v (t <br /> /� !N cit G��/�-/ (//V ✓(/V /t <br /> �// �C 50 = L /� cit <br /> 13 0�iLi1yV; City <br /> lf o � to 3lzl3 <br /> Cit <br /> a. // / % ��� CU R0"q-D city 5?A& <br /> 2ld t // <br /> /�/A�_ /6Q cit � ( � <br /> 2-2� W' h 12L/11L�//�V,7/� cit / ��^�� v �� <br /> /Y�lKf l `/ WE- Cit /� oJl�(J j l 1/ <br /> / <br /> ///- /Z-/7 <br /> om Cit <br /> 6 !/YlGCJ/ (,GA Z- (ncity ( /✓GG/ f ( l/ <br /> A)4,a3 %�t1 �� ti� cit <br /> Cds cit <br /> Page�_of <br /> EHD 42-04 <br /> SEPTAGE CLEANERS REPORT <br /> 12/27/13/13 <br />