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SAN JOAQUIN COUNTY <br /> L x ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 12th of each month <br /> ���.«�.�;;a• Telephone: (209)468-3420 Fax:(209) 464-0138 Web:www.sjgov.org/ehd <br /> Q SEPTAGE CLEANER'S REPORT <br /> Company Name: �l� (li'��f�l/Cl �O - Report for the nth of:1l year av/ <br /> Company Address: 1/3 fCl�64 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) GREASE TRAP FACILITY <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY (C) CHEMICAL <br /> City <br /> / Cit <br /> J—o Ae,,r--1 Al i ✓dile City <br /> / ��G//oy��U/✓ VIII / &�rCl�/ if�. l���/1!/1{(�/� q Cit <br /> Cit <br /> City AIR? t <br /> Cit <br /> e'dOv✓9�05 Cit <br /> 3,-2 Ly rl/i/// c/ Cit <br /> % ,�7v7 . ///�/l�/T L®Yr/1/� Cit t I( C <br /> L` i►//9205 I Cit <br /> a L7 f lr Cit <br /> Gt) <br /> 4- 10952 / AN-1– !•!i1¢L Cit <br /> Cit <br /> Z311 &4171-t city <br /> ' ✓�t AC/'t AIJAIU Cit <br /> T�Cv v3 7/L/ / 9r��/l �S ✓,� Cit <br /> Page 3 of 5 <br /> EHD 42-04 <br /> SEPTAGE CLEANERS REPORT <br /> 12/27!13/13 <br />