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SAN aJOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> / 1868 East Hazelton Avenue, Stockton, CA 95205-6232 12t" of each month <br /> • �. ;*P Telephone: (209)468-3420 Fax: (209) 464-0138 Web:www.sjgov.org/elid <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: p(/l SX jV Report for tf onth of"1661'L' year a <br /> Company Address: Signature: lay <br /> Street Address City Zip Code <br /> All information submitted must be complete, accurate, and legible <br /> DATE NAME OF BUS114ESS OR (R) RESIDENTIAL <br /> ADDRESS WHERE WORK WAS DONE GALLONS NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED (G) GREASETRAP FACILITY <br /> PLEASE <br /> INCLUDE STREET #, DIRECTION, STREET NAME AND CITY (C) CHEMICAL q <br /> Cit !! J <br /> cit <br /> /3 s;w wr� c J TSC��uIT� *A:� city <br /> 010 Rr9lq� cit <br /> Cit <br /> cit t 7,., t ► <br /> Cit <br /> Rim ti we( / 7�' e !�l/�5� .�clJ�,r(!� lea cit <br /> ICity <br /> S4' / 78 /� �sC°/TL 1�.r�� R Cit <br /> bus GlJh�x s�C / $' v G�EsT�Su u CTS' /eO cit <br /> cit U) &7/14C 571v c ► <br /> YAW 8111'D �q` c Al L'�/v ku,4,0 cit <br /> Cit <br /> City <br /> City <br /> Cit <br /> Page Of <br /> EHD 42-04 SEPTAGE CLEANERS REPORT <br /> 12/27/13 <br />