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a cati SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Return this form by the <br /> `�7;�:ty,��+��• Telephone: (209) 468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd 12th of each month <br /> o SEPTAGE CLEANER'S REPORT <br /> Company Name: <br /> L �' th of: /L� yearo2 <br /> Company Address: ����/Z��% �! �,/��� Report for <br /> �� JQ�� <br /> Street Address city Code Zip Signature: L�%Q ✓ <br /> All information submitted must be com tete, accurate, and le ible the <br /> DATE NAME OF BUSINESS OR <br /> PUMPED PROPERTY OWNER ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAL <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CPUMPED GREASET NAME OF TREATMENT <br /> C) CHEMICAL FACILITY <br /> 'J' cit �C?,0� ITY � -` ;. <br /> Pa 010; S� 0,-Al, /D 9 .f/ptiitf oS' C t > > /5?��� ,, <br /> c • ll -C ity <br /> N-Dui <br /> 90 — Obi/� �ri� u� E — <br /> cit / �f �� <br /> rlava� l«t Ste- '?,SGf/ <br /> EEEI <br /> Cit <br /> L��r � ���✓f>'WI, ort o�.3 � , , � � <br /> Cit p <br /> R �� ' P, lI /YJ.9�e✓Si sc� < <br /> Cit <br /> Cit <br /> D City <br /> /l <br /> Cit <br /> Cit <br /> / cit / <br /> 9i !/ <br /> I/ City 4 t f <br /> v city t <br /> Li'�,�s;L� . T_ cit <br /> I I <br /> City <br /> Page of <br /> EHD 42-04 - <br /> 12/27/13 <br /> SEPTAGE CLEANERS REPORT <br />