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EDa,sul , REC A !f <br /> SAN JOAQUIN COUNTY <br /> r_ ENVIRONMENTAL HEALTH DEPARTMENT APR 0 9 20 (}Return this form by the <br /> i <br /> 1868 East I-lazelton Avenue, Stockton, CA 95205-6232 12th of each month <br /> Telephone: (209) 468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> ENVIRONMENTAL <br /> SEPTAGE CLEANER'S REPORT PERMITISERVICES <br /> ((�� n � � , / <br /> Company Name: l ) � Y� �/v C, - Report for the onth of: C6 year L� <br /> Company Address: 9�1%i� .c�`t ��P/ 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 /> � AI,C �L oJC /U e / as/L //� ca <br /> aL C hRAA /y gas �Tl�i!�2l Cit y <br /> /S•�Vo X / City f �67)�f /r <br /> 3 Ig�i 4 790 ALJ U Cit //0 1&14 lJc� r l <br /> U rzcCf- l 0I i , z <br /> `� cit U <br /> �I�1,- � /lkl✓► CI I✓. /l' Ald It lise a;� � �i- �D Q l vcS <br /> cit ?��/ <br /> r)0✓t�Q� / Z / � �`/� � Cit l C✓� t l ! I <br /> /, S//✓ U 0 % / 1y1 (/��✓C cit <br /> U r9Z/Jl a3/� w Cit <br /> o5l••E &l 4vz r.J cit <br /> �'/�'�.c)®' ( - Cit <br /> 40s�w0aD c4ill 02 so"71-6/ 'Sexi/ a� v/� Cit ` ' ✓U(� [ i � <br /> Gt�l�i✓��l�clf�� "2 6 GIJ i "n'4471 R J,9•D Cit l 1 3 (700 <br /> / lW ri Ga.l-l(� S01 Iy%I�'VS2 GA/. Cit <br /> G1O0 PC�z�- a yo/ City �� / 6-�j0 , , <br /> GU ���< wE6///y�7�//1�� �U '✓Fi Cit <br /> C,001/6 14)a cit <br /> Page / of -5— <br /> EHD 42-04 <br /> 12/27/13 <br /> SEPTAGE CLEANERS REPORT <br />