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r�& <br /> SAN.�OAQUIN COUNTY <br /> ENVIRONMENTAL H EALTH DEPARTMENT Return this form by the <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 12th of each month <br /> Telephone: (209)468-3420 Fax: (209)464-0138 Web:www.sigov.org/ehd <br /> SEPTAGE CLEANER'S REPORT J <br /> Company Name: - « /fl^�t/TD hplJQ.�Ij j1. b)m sRe- J�i�D%otlGl Report for the onth of: /� Cl// <br /> T---o--- �_ year216 <br /> CompanyAddres s: ll3�171%� �( �'9C�l��52J?ij Signature: <br /> Street Address City Zip Code <br /> All information submitted must be Complete, accurate, and legible <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 C CHEMICAL FACILITY <br /> �/as /5 L,�o�/Zi !►�r C7i04/ /!�lI G'L- <S /�at/u E Cit L U / vaa �vE/�6-YDI S <br /> �Pv/l cit is <br /> City ;4( J 1 <br /> So P11-IAl L Cit <br /> Cit <br /> Ci <br /> C u� l� o�x/75 GI/ l y�/ i'� Cit 6 OUB <br /> 6JJ n777 �a1/ LS-r- City �� 0 <br /> cit <br /> Cit <br /> vZ� cY7/47- )WiM //72 N, Cit <br /> 'hl�d7" (-TCit <br /> t' A Cit r �C1lJUJQ I! t <br /> 1 <br /> City e TI �l > <br /> &00'(y4 s- Svcc7/t cit lite/:::: <br /> , 5T-A0YhtF x -7/ ?' »'llzll.C/!J Cit 50J t� ! <br /> U(J IJUf 6v�auiZ /U D .� T�iit/i% G✓ cit <br /> Page of <br /> EHD 42-04 <br /> 12/27/13 SEPTAGE CLEANERS REPORT <br />