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RECEIVE® <br /> *xb: <br /> AUG 12 ZOiSSAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Rehurn this form by the <br /> 12 of each month <br /> ENVIRONMENTAL HEALIf4lephone: (209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd <br /> PERMIT/SERVICES <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: <br /> Report for e m nth <br /> s: of: Jae' year oZ JStr /S <br /> Company Addres '- L- ���1y1 <br /> Street Andress cit Signature: <br /> y � Zip Code _ <br /> All information submitted must be Som tete accurate, and legible <br /> DATE NAME OF BUSINESS OR <br /> PUMPED PROPERTY OWNER ADDRESS WHERE WORK WAS DONE GALLONS �R) RESIDENTIAL <br /> PLEASE INCLUDE STREET #, DIRECTIONE AND CITY PUMPED, STREET NAMGREASETRAP NAME OF TREATMENT <br /> FACILITY <br /> CHEMICAL <br /> / city%�'t�v <br /> o -cru, E2 r8aya �, / <br /> Cit <br /> l 'IA-Aly ae !/ IAoo ejxo City <br /> I <br /> t / <br /> a� -9 A-)vNo Arer '250 > > <br /> 3� �i✓�►/—G2tiicit <br /> � <br /> Q� d# E2liQa/AU.5'-.O Cit <br /> /� �!/,/ / g <br /> city �v <br /> 6' <br /> 10 - <br /> Cit �dlJ t i <br /> ,,''//4/ 9 i <br /> 23 �// S /s'J L�9�1/,e Cit D oct) <br /> Cj,�'C� f J/l • <br /> 6-301 6,gjn1 /�/l C t <br /> 1 , t <br /> � lr./( ��/�' .��- OS r1✓ %6f��/t/ �c7,9- J I401-2 <br /> / ilig,/ cJ 01� 'L cit <br /> City <br /> ! <br /> ------------ <br /> Cit PR 0 <br /> cit 1/ <br /> it <br /> EHD 42-04 Page_�of <br /> 12/27/13 <br /> SEPTAGE CLEANERS REPORT <br />