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Q►guln' ° SAN JOAQUIN COUNTY <br /> { ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> d <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 /> SEPTAGE CLEANER'S REPORT <br /> Company Name: 01�C4 &0 Report for the th of: year <br /> Company Address: Signature: L Gif/ <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 (O') GREASETRAP FACILITY <br /> ? PLEASE INCLUDE STREET #, DIRECTION, STREETNAMEAND CITY �-7r (C) CHEMICAL <br /> ( as Cit t��� �� / ,J vL s w <br /> '861 Fw& W Cv !Fj'C. Cit <br /> city <br /> 3 ` J Cit <br /> JzVk2127 D ��feN liE city fS <br /> SW W140 W4WAW a l c- // 7F Cit yy(fL t 6 If <br /> cit <br /> O f 6—W e4 d RD City 411 <br /> 9✓ L !1L✓ cit <br /> L7 _,0,;' G/)V*!E7 cit 7 I v ( ( L I <br /> 1U19,0 Cit <br /> — L cit Z l 1!111 r t C <br /> cit <br /> ,_© &1 city « !/ <br /> city <br /> cit <br /> cit <br /> Page of <br /> EHD 42-04 SEPTAGE CLEANERS REPORT <br /> 12/27/13 <br />