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r4�tN19 SAN JOAQUIN COUNTY <br /> orcr-'_ca._c <br /> z ' ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> I i 1868 East Hazelton Avenue, Stockton, CA 95205-6232 12t" 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: /� � &Iyy / k Ce) w'me �inlDJ�i/��(�.. Report for the onth of:.4LR/�,C��year <br /> Company Address: /3s� �r. ,�'L ,��{o ��, , �i �SQ3() Signature: h <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 p, DIRECTION, STREET NAME AND CITY C) CHEMICAL <br /> ,7 ZI / � S � � iCity //-//5* A�D� <br /> /lIFAST GE �rvcE/� Cit <br /> city <br /> t /( �00b <br /> c <br /> 1-2 ynrlz;ov"i�z City <br /> 702 Gv lniV 02L,' at J/ 1-5-0 <br /> .� CR✓ /�� 8 U Gt/�S i lyl.�GIGI G9�/� cit %5Td 0 A (d �22 <br /> City T If t I <br /> �f Q' ,�I--CJui�B�al 2727 C+/,/�'I.�4��/C�� Li�i✓�t+9 c ity <br /> Cit <br /> dc1lwr5- cit <br /> /7U /lv <br /> �7 cit <br /> Cit <br /> cit <br /> G,z /1a City l <br /> X. / ,S� /!'1 /7//9d✓� cit <br /> cit <br /> Page of <br /> EHD 42-04 SEPTAGE CLEANERS REPORT <br /> 12/27/13 <br />