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ap4H t?r,� <br /> a SAN JOAQUIN COUNTY <br /> " r * ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 12th of each month <br /> �*r; Syyi+�4• Telephone: (209) 468-3420 Fax: (209)464-0138 Web:www.sigov.org/ehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: � Sn� C _ <br /> ' Report forthe onth of: years , <br /> Company Address: ��3 %�C� � <br /> StreetAddress Clty Zip Code Signature: <br /> All information submitted must be complete, accurate, and le ible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAL <br /> PUMPED PROPERTY OWNER NAME OF TREATMENT <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY PUMPED lGREASETRAP� FACILITY <br /> / / (Cl CHEMICAL <br /> (/(l Us <br /> �L T Gl/f 7 c 6?6 V 3 iY �lcr�11.14 C ity evL) <br /> L S Jb- 3-�0s Gr/C�rl 41nrCity <br /> /lo �,V-J17 <br /> "VIE Cit i / Svc <br /> City <br /> 10o el' A� Gt/,7S&v 4V,, <br /> City <br /> ce> l I-);vE Cit <br /> h1/fl)av/ ea r 3/x/3 city <br /> Cit i2,4 ea <br /> a/ �t,�n� ��c h.�✓ �i' W cit i� 467dS (� ale�= <br /> S -�' City11o1 %1 , i <br /> > 3ai — �G> Cit �� sad t ,l <br /> z ��/',� r cit i/ SUv <br /> L0 0 cit <br /> t Lf cit <br /> G <br /> 1'7-6 jo�V7 (/,/mac cit 1 r �dvz <br /> Page_3 of <br /> EHD 42-D4 <br /> 12/27/13 <br /> SEPTAGE CLEANERS REPORT <br />