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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 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 <br /> Company Name: 11i�/j Report for the nth of:� _ year d /S� <br /> Company Address: ��✓����/, �=/'( a � /�� g3L Signature: <br /> Street Address Cit ' <br /> Y 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 NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED GREASETRAP� FACILITY <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY C) CHEMICAL <br /> �//�/s ,Sz,,n�,�,-i 3�a a �L- <br /> Citv 77c /5 u G /7W O 0014AMifS <br /> /�c -f aslrl/ G'GOv61 AD, Cit <br /> (;vs✓�� Wb�t7CrS%�l� <br /> )70 50 City <br /> It �l <br /> �0 1�e)z J 21 70 Cit <br /> ' %v W/ 'F'✓i tl A /79 80 GI/S e-Na M-5-•- R0'q-O <br /> cit <br /> Quos T Fre 6 L- cit / <br /> �J� ', r _e <br /> I/ �c5 GJ/f016SM E / CJ 90 1l/ 3'e-3'eL ��/ Cit <br /> City t/ <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> City <br /> Cit <br /> Cit <br /> Page of <br /> EHD 42-04 <br /> 12/27/13 SEPTAGE CLEANERS REPORT <br />