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at•4u1 ' o SAN JOAQUIN COUNTY <br /> s..�,.cra-•.a <br /> r,. ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 12th of each month <br /> . ;<«�,��;;�• Telephone:(209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd <br /> p SEPTAGE CLEANER'S REPORT <br /> Company Name: �/\ Report for th n t of: year <br /> Company Address: <br /> Street Address City Signature: <br /> 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 GREASETRAP FACILITY <br /> /PLEA/SSE INCLUDE STREET #, DIRECTION, STREET NAME ANDCITY (C) CHEMICAL <br /> /� 7 / ��/ //>!il/ Cit ci�� fv �/ ` j' � s <br /> ^ fj r ✓ 4/ <br /> �✓�� !'�A/ Cit <br /> city 7 t d <br /> l / /V0 tT Cit , l 1 <br /> Cit <br /> Cit <br /> 1 1/ r( /4l/1 Cit <br /> City <br /> / s� fO16'04 City <br /> 7!' J <br /> � <br /> / cit <br /> ✓� / /�,,� Cit <br /> Cit ✓ U r l �l <br /> ��,/I�✓{��/�/ <br /> CityI /� <br /> SO 4131 ////Tr`e /,, Cit p 99 L U� /t I <br /> Mix. � ? 1 City <br /> /79 �oS� �' & Cit <br /> C Si9L�' / /'.�/��/7,(/ice h� Cit /i i l <br /> Page of <br /> EHD 42-04 SEPTAGE CLEANERS REPORT <br /> 12/27/13 <br />