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d�gt{I� <br /> SAN JOAQUIN COUNTY <br /> " ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Return this form by the <br /> `'cfi�aw ��p Telephone:(209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd 12 of each month <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: &K � S 6 _ � <br /> Company Address: <br /> Report for the nth of: Jz year <br /> Street Address A City Zip Code Signature: <br /> All information submitted must be complete. accurate, and le Ible <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 CITY PUMPED GREASE TRAPS NAME OF TREATMENT <br /> C CHEMICAL FACILITY <br /> A <br /> f G � l✓/� �T cit <br /> �i� 5��91� <br /> City <br /> Ile /.,---z�6/ti TO a yy/ �� Ci <br /> IR 0 Cit d�G l ( <br /> 3�y3 / � ���! /owz cit / <br /> 141Wi elves T /sv� S GJ t <br /> yy � Ci t c/ <br /> pit �� <br /> city /I <br /> ci <br /> Cit I� <br /> !�L �Ilp h// <br /> �iJ�✓. os �3W3 1�/ � cit <br /> ) yr ci <br /> cit <br /> 4 . 8. 0j - <br /> Cit / <br /> sc��ovrr��L A101t -22 city <br /> R c'd S /R�4 L <br /> Cit <br /> EHD 42-04 - Page of <br /> 12/27/13 <br /> SEPTAGE CLEANERS REPORT <br />