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QRgNI>Y, SAN JOAQUIN COUNTY <br /> , a-•.Citi <br /> ' ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-623212tH of each month <br /> . a. <br /> t�aTelephone; (209)468-3420 Fax: (209) 464-0138 Web:www.sjgov.org/ehd <br /> 4c �a�`� <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: 1,1)4 <br /> Report for th nth of: 10AILI year <br /> Company Address: AIIZ�/% '& SM44'nry m j 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) RE ENTIAL NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED GREASETRAPj FACILITY <br /> PLEASE INCLUDE STREET N, DIRECTION, STREET NAME AND CITY (C) CHEMICAL <br /> -/ �2/�✓ 3s/ � ie^cTng4/ �_/ Cit <br /> ' ��/�/1fV(i/N� Cit " 5?)d A �r <br /> 6� City 7 /f <br /> f"IgdA427-2 &1//��`/Cow Cit <br /> /Z v�/ / //�c�✓i � Cit <br /> ,2)r Cit <br /> G>l�v( /788J iris �. Cit try t I <br /> GfJ�il/D W Ct7M Cit <br /> C it <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> City <br /> Cit <br /> Cit <br /> Page of <br /> EHD 42-04 SEPTAGE CLEANERS REPORT <br /> 12/27/13 <br />