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SAN JOAQUIN COUNTY <br /> ?' •s <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> `=rt -• 1868 East Hazelton Avenue, Stockton, CA 95205-6232 12t1' of each month <br /> +�; �• ;� Telephone: (209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: ��� j � �R� �/�C _ <br /> Report for the h of: yearo7(//,5 <br /> Company Address:/ j/-"��� �; �� yy�� � �� Signature: <br /> Street Address City Zip Code <br /> All information submitted must be com tete accurate, and le ible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAL <br /> PUMPED PROPERTY OWNER GREASE TRA NAME OF TREATMENT <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY PUMPED FACILITY <br /> (,-�/� CHEMICAL <br /> � <br /> Wim(/ /r cit C'!L/l/d� <br /> o J'//� �� /_M / <br /> Cit <br /> j @ <br /> Ci <br /> ty <br /> / / %� Cit <br /> cit, <br /> 4G113 011-12Ae- CitR4 <br /> �.6- 01W Cit <br /> ,e /C/J o✓�,o Cit i I ��%L J r I ! <br /> // 3/ 0N L ! /`oA) Cit <br /> /�/�Uv�✓ �� / e G!/�S'/��/�� �;— Cit <br /> cit <br /> Cit <br /> Cit <br /> Gf4L2i/y 8L cit <br /> . .S o city <br /> rr/— i Lp tl D- cit <br /> �a � wNv� J�C� /7 �n ct/SEi�}u Lid Gz0 Cit <br /> Page of_� <br /> EHD 42-04 <br /> 12/27/13 SEPTAGE CLEANERS REPORT <br />