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°�4%AtM' c SAN JOAQUIN COUNTY <br /> L' ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 12th of each month <br /> �i<«�.�;:*• Telephone:(209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: SLr) � <br /> Report for the month of: years7 <br /> Company Address: 13J5D � <br /> 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 (C') GREASETRAP FACILITY <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY (C) CHEMICAL <br /> City <br /> Cit BPVW <br /> i 2 /7v3 /= /i/�J�J l /%� City <br /> —1 /�.l�i � //7� )V•/i�/Ji [7 ���/ p�— �/� Cit <br /> �S Fdlit �/,2 C Uv ��/01/ Y/l�' / Cit <br /> Cit <br /> cit •S J / 1 / i <br /> ` Say Ai:-� Cit <br /> Cit <br /> l �Uz1a Cit -5W I L l 1 <br /> o m z41✓,6" cit <br /> r <br /> cit ! I 6 ZlJ r l c l <br /> � t C cit /I <br /> Vt/ L it( AF�T 6 C E- Cit <br /> 1J �riZTvs 3 W91 4t G-,✓2 city <br /> 1 J)44 cit <br /> l3 Avlw c hw / /6'Aul AAVIWOit 14-1/2— cit <br /> Page of S' <br /> EHD 42-D4 <br /> 12/27/13 <br /> SEPTAGE CLEANERS REPORT <br />