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Or'4u1 ' ° SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 12t" of each month <br /> ��cPkns��,p P Telephone: (209)468-3420 Fax: (209) 464-0138 Web:www.sjgov.org/ehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: �/, a U 151Q a d Report for th month oUl✓ e6 W year <br /> Company Address: �✓�,5�Tc/G� �L �f/�,, 61w .3 il,7 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 /> s o?5 D ✓ 11�r✓�� Cit yC' d o�Ffs <br /> 1,47/51w; "VI DIS a2s G !� L1/c . cit ' r <br /> rt, / ✓1hi,&' city <br /> L13C /CJJ �.2 Cit — <br /> 6Ur9alz -,02,37 lac- cit sed 1 <br /> gao l cit <br /> ll c cit / c <br /> AJi! L i /� � Cit /( 1 <br /> City / v `�— <br /> (/r/Il�� /—UvC7S S f LZ�. cit <br /> `% cit a�0 1 , <br /> City <br /> / / <br /> Cit (J- t1l � L lI <br /> V%✓�Cr(� I�% - 4 Cit �� SCJ II / <br /> -R:3 5-M / �`v Gll�S�/ �� Sire city <br /> AS <br /> Il 6 lr - / 7 9so :t it'd Ala L T,0 city L) i <br /> Cit <br /> Page of <br /> EHD 42-04 SEPTAGE CLEANERS REPORT <br /> 12/27/13 <br />