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RECEIVED <br /> Q,,qutry ° SAN JOAQUIN COUNTY NOV 1 4 2014 <br /> z - ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-623 NVIRONMENIALRERLTH 12t" of each month <br /> .na. P Telephone: (209) 468-3420 Fax: (209)464-0138 Web:www.Sjgov.9fwq-/SERV10E8 <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: EA/ //�� <br /> .S&D` :� "7 w Report forth o th of:0�70166-�z year R")ILI <br /> Company Address: Signature: <br /> Street Address Icity 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) GREASE TRAP FACILITY <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY (C) CHEMICAL <br /> i <br /> Cit CZ'44 A <br /> Cit v 04. <br /> 96 N L city /I 0 <br /> JTd c <br /> 0.0 city <br /> cit Q t / <br /> j 5—p0 cit <br /> 7D �U f A) Gv. f= cit <br /> J ' 2 92 0 VJ. &r116W ,92- / cit <br /> '72 1"Aa e c it <br /> C e 9 211 6301 Cit /t <br /> a-7 Cit <br /> ,57iv /t e <br /> cit <br /> 31 /5 av�l %O cit <br /> &)LA �3� ]� Z,9cvE;- Cit �, <br /> d y�sl/6 City flt�� ^�p7L(Je) <br /> NI/ 3-)/ V ` %//y e).�//ji�V S//6 �/�.�^ cit <br /> / eZ Ad//0 lit/ / 30 /_ `' �S %/ /7UC Cit <br /> Page of <br /> EHD 42-04 SEPTAGE CLEANERS REPORT <br /> 12/27/13 <br />