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SAN JOAQUIN COUNTY <br /> z <br /> ENVIRONMENTAL HEALTH DEPARTMENT JUN 15 2015 Return this form by the <br /> 1868 East 11azelton Avenue, Stockton, CA 95205-6232"+h 12th of each month TelephOl7e: (209)468-3420 Fax:(209)464-0138 Web:www.sjgov'otg/ehd` ?TAL HEALTH <br /> FRVICES <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: 4J, 'Vy %OJC <br /> Report for the ith <br /> Company Address: �,5� <br /> Street Address City Signature: l� <br /> Zip Code <br /> All information submitted must be complete, accurate, and le ible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R <br /> PUMPED PROPERTY OWNER NAME OF TREATMENT <br /> _ PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY PUMPED G) GREASE TRAP! FACILITY <br /> C) CHEMICAL <br /> r►.L/iJ-!�u/�yn/yrh�/ ,U Q G �L/1a/ �112�nD cit <br /> /✓- v 0([//'/�7r/ �U aG/� <br /> 1'1q It/ �/t A0 Cit <br /> City <br /> Tj cit r' if <br /> U L&1190— a yv 1 ,ft pit / L) t I I <br /> vo City /s ? , t <br /> d/ I-)w44 cit Gv 1'rJ/1 <br /> City 52 � C � <br /> L°f oi✓/9-�C0S rGyL�l, ��f/ l/1/�✓l Cit <br /> 1�,l I/ f (� �/� /YI/�0✓ Cit <br /> a0 L "S I cit <br /> /19A1 lel P4- c /i�/ s��'� ����r/��v� Cit 01/ <br /> dd <br /> JQ �� • % l//� (rl1, iT1� G�4vl/�= cit <br /> Cit <br /> i/�%��� S%`/�✓1/�) j�(7�/lt� /T/C G�/�G /."2, cit <br /> c7o" sTAnif�r�'I /a 9/Y �1'H �' ^( �S� Cit <br /> Cit <br /> Page---/—OCT: <br /> 42-04 <br /> 12/27/13 <br /> SEPTAGE CLEANERS REPORT <br />