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Qquln c SAN JOAQUIN COUNTY <br /> L ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 12th of each month <br /> r;ft � :r Telephone: (209)468-3420 Fax: (209) 464-0138 Web:www.sjgov.org/ehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: Report for th nth of: G'/1 year,-,'-?o/.5 <br /> Company Address:/� G� �_ J�n S� (� Signature: l% <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 NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED 0') GREASETRAP FACILITY <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY (C) CHEMICAL <br /> cit dl/o G° /�G✓ 1 U U �O <br /> City <br /> G�IT,au� a .6,� g�- fr <br /> cay �v ? <br /> bl)"'LSpa) cit <br /> /0e-o Cit <br /> —Ilk 6M Fly City /6i t i <br /> lr at <br /> City d7 �. <br /> y '"� � Gt/ Gv``S7C/�'T�11✓lU /Ca� cit fl �/J 1l 1 <br /> 4,E Cit // <br /> cit <br /> Cit <br /> - :2 c <br /> City <br /> Cit // <br /> J <br /> city <br /> Cit <br /> City 0vJ <br /> Page of_� <br /> EHD 42-04 <br /> 12/27/13 SEPTAGE CLEANERS REPORT <br />