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r4!tiry <br /> ?°e.cr-�pati SAN JOAQUIN COUNTY <br /> z ` ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 12th of each month <br /> rt •. �P Telephone:(209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: Q j CO• ¢1.11 We Report for tB� <br /> � � e-month of: <br /> Company Address: ��� �(iG,= 8( ,2, j�/✓y� ly',Sf3�') Signature: �G <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 NTIAL NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED G GREASETRAP FACILITY <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY (C) CHEW-AL p <br /> 0/110wrwI City <br /> Cit <br /> LH.✓� aty <br /> c�Z- .27.2`7 Zd 19117076,V 41WE Cit i f X511 <br /> f}st/ /07/,0 cit i r e57Jt� tt I <br /> 3 s/� S-60w#U�JW« m. 700 tvko-��kcre-- A40 cit y5;V0vi <br /> dzt-Aw�s-f <br /> (jureya*&&9j� e 172509,0 Cit Z/570 C) <br /> , I <br /> .✓u� © � nT i Grp' , it-�� �tiT Cit <br /> cit <br /> /l)' w Aal'52t Cit I 5'Uv I t I <br /> r <br /> City /Ud I <br /> r ) 41d " 61 city - <br /> / �-��•�u— cit <br /> Y'Po <br /> City <br /> A7 01 4/ 1_ 9_rS/%! City I I Sd <br /> 0 Cit <br /> a3127754 L&Z&4 #L /-7,9'19D hl, SChh/C%� alaKo cit <br /> Page of <br /> EHD 42-04 <br /> SEPTAGE CLEANERS REPORT <br /> 12/27/13/13 <br />