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'441ry' SAN aJOAQUIN COUNTY <br /> r 4 ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> t� 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/ehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: ; .- Report for the o th of: /0 year o21�/L <br /> Company AddressSignature: Lt/ <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 (C) CHEMICAL <br /> C ,, LL j 1,42 'SCity �� �� c f�(�,�/T!�!✓�G <br /> �i ,57 6e.2�jr : E Cit <br /> 13110 Yz,Errs City <br /> a N UMC! I/*L F o-Ay —JA,,/�S/ 0SC % City <br /> / /��� /l: ��'/ /( L Cit ! I t c y I <br /> 2"2,A7 Gil. Cit S}ieC'rE��✓ ,,�`-p 1 I S (/Z1 <br /> 'v 'S 3�y3 G✓��Si GfI /� city f <br /> %R ,� cloZ9rl Cit 1 I <br /> c L Allo ,S/0 r' l Cit <br /> fS', Cit i / � <br /> 1 AC /l./- G `7Io0S �' i �/ Lil(l /�� Cit 7/ 0( ! t /t <br /> a 7� GU�`ls©�✓ Cit L <br /> p�(Ju/�% s�/7�v� Cit J / / <br /> 46- �° /91ly aY <br /> 3/0 !f l�/t Cit <br /> S/ « © �iQ7YC City l ODD 1• l t 7 <br /> Cit <br /> 3�� GU Cit <br /> Page R of <br /> EHD 42-04 SEPTAGE CLEANERS REPORT <br /> 12/27/13 <br />