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Qr,.auln' e. SAN JOAQUIN COUNTY <br /> z ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-623212tH of each month <br /> Telephone: (209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd <br /> c n SEPTAGE CLEANER'S REPORT <br /> Company Name: �1 (,JO 10/ l Report for the onth of: j9 ? year <br /> Company Address: ��3�� tC% � 166 /r' .5�� 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 11 (C) CHEMICAL <br /> a()50 Cit �vV - Odd Q <br /> uNw l SmvhEo rn. 1- 5^ 1._/.( �/i'%� Cit <br /> City <br /> /✓ /�/r �()/If/ I� �l/ / �/t!!// � � �r/l(�T/// <br /> C ity sno <br /> / ti ' S. Cit <br /> a✓,a/ i / c/11 / d�,�r�i TE�Ii/r✓�t Cit <br /> Al SQ- A � 0 Cit <br /> I'51X ACV m a 2s"'G•� i �� /� Cit <br /> aT4V) 9//l�t�. Cit ! C/ <br /> �v✓ QS 3 �� ��� Cit <br /> City <br /> hZ- Adllb (060 15-10 <br /> Cit <br /> /(, 7 &t cit c / <br /> o ua)i uE Cit r UvJvr/ <br /> iY� r r !(,fes^ ( City <br /> J O/(J V -� % - City <br /> a-2a 7 w. 11 Z--5q✓,`- City A.0,,7jJ--J- <br /> Page of 14 <br /> EHD 42-04 <br /> SEPTAGE CLEANERS REPORT <br /> 12/27/13/13 <br />