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SAN JOAQUIN COUNTY <br /> •tri-•.6� <br /> z ` ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 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: /Wql > Report for the onth of:1)h.1me, year ay/�$— <br /> Company Address: / 3 ) Signature: <br /> Street Address City Zip Code <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 NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED C' GREASETRAP FACILITY <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY (CJ CHEMICAL <br /> �7 ,Cvoi ST iUry1�� CiN, /(� &Z Cit ,1C',4)/ lw�)S s�l�dr�JvGI�J:S <br /> 3 /,(67- v � I City ZWWg/ <br /> / � D 60 8;i1l city <br /> Cit <br /> Cit <br /> t <br /> lklill Solo>rig2V-7-!; ry 7 Cit <br /> cit /Z— <br /> .S4UC mivel-1 t/ C ity I1 UcJ i I <br /> Cit <br /> r✓l G.e G �3v/ <br /> city (JU U l <br /> Cit �/ j / r i 1 <br /> Q 2 , Cit <br /> 7 n , ✓R17ldAh city <br /> 2 L 4A6 Al 2Q. 296 cit i 5-6� <br /> city <br /> 3 Cit <br /> vZ ll �Gt iG✓l / � %�/r9 %�1 � Cit <br /> Page of <br /> EHD 42-U4 <br /> 12/27/13 SEPTAGE CLEANERS REPORT <br />