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ataulzy' HY <br /> SAN JOAQUIN COUNTY <br /> z ENVIRONMENTAL HEALTH DEPARTMENT urn this form by the <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 FWFf each month <br /> Telephone: (209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> SEPTAGE CLEANER'S REPORT R 7Q��, <br /> Company Name: Report f P 4 year c <br /> Company Address: ,3 �i i �! 3� 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 /> Cit <br /> Gr1 �✓o s /EN Cit t C) <br /> �ON - City <br /> r �C Al —1 bV 040 Cit / <br /> o`? City <br /> Cit <br /> / cit <br /> - vv0 <br /> G /�'� f �l/�J �%� /TNz-- cit �I 7U <br /> i , (] IAV M-y/d Cit / <br /> n'I i Il�a Al hWill si, City <br /> Sly <br /> .$ Cit <br /> L/7 ;�7UA `% 41 Cit r orl?1 <br /> 3a3 GUT L2 4s*/C Cit Sd l <br /> i li �2 9(1 9)-] d�iQ ��/�7 City <br /> S .3 7 "' ✓' GvY"- Cit <br /> e�v.✓ S/y/ C) / at <br /> Page of <br /> EHD 42-04 <br /> SEPTAGE CLEANERS REPORT <br /> 12/27/13/13 <br />