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SAN JOAQUIN COUNTY <br /> •e,Rca--a <br /> 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 /> rks'a� <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: / �� lti %011 o Report for a mo th of:/1/(J// year //7/ <br /> Company Address: /� (,i 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 /> ��7 -✓�- (3�rs>/�jL �9 Cit <br /> o`�G •v- �o Bue�y f1A� cit <br /> 3 m/y9i S/9fll C 69' o 13 v soul H ' ai In o city D •�(7 <br /> Cit L7 <br /> S u'f� 61 C'fl. .�a LS 44niZ Cit <br /> Baa �ti <br /> City <br /> Cit <br /> cit / r Spv <br /> /C e�J�✓!�'� ,S / tr'�4��� i�,? 991/ cit i <br /> —el <br /> J <br /> cit v <br /> Ieoe )Alo(or 312 City <br /> Cit <br /> NiNl u // dI ,9 S-0"TIf 01*4 a cit t a <br /> � �a 041A6r410 cit <br /> City t <br /> -- <br /> - <br /> �Dd i.?A - it I&OV• /U /✓DIL y"2A6& &AfAr City it r l <br /> U A 7� � cit CUr9� <br /> Page of <br /> EHD 42-D4 SEPTAGE CLEANERS REPORT <br /> 12/27/13 <br />