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Q.,au l>w <br /> ri-CO . <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 71 1868 East Hazelton Avenue, Stockton, CA 95205-6232 12t" 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: l �'l,ms(�77� �m j (dp, Report for the nth of:f �LJ year A <br /> Company Address: ��.3j�0 'E/ /L.e4 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) RESIDENTIA <br /> PUTL NAME OF TREATMENT <br /> MPED PROPERTY OWNER PUMPED GREASE RAP FACILITY' <br /> PLEASE INCLUDE STREET q, DIRECTION, STREET NAME AND CITY (C) CHEMICAL <br /> /-,gf v ll-76/✓v/27-/f ci <br /> '7-0 8613#Wif t, cit �IAcity <br /> QAW a af/D�T� �!C .�% cit <br /> G'v L3� 641n) Cit <br /> fv 35V F7 n� cit <br /> lfo w� / UAn cit <br /> 13 /'L(8 /� U/ X59.-S7-M 0/�/g0� A/G cit / � I? <br /> P` W-0 / /V+ 17) I tsOA/ LT/ Fi�/ cit <br /> cit <br /> /!7Q U ^ i v rS <br /> �&M-t & Cit <br /> 6a E. 9--l- rr�r � cit �Ua t l <br /> Gi/f�v J a y39 h'//t��tf Gi9fr/� <br /> City A L) <br /> 2 `7a 7 11V In fib AIL- Cit <br /> . n1lyl-� / city <br /> 7—,00,0r- y7jo�5� U/I i �Gl�( cit <br /> V l �✓� /•?a A4 go-all, /' Cit <br /> Page of <br /> EHD 42-04 <br /> 12/27/13 SEPTAGE CLEANERS REPORT <br />