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�quln SAN JOAQUIN COUNTY <br /> 0." <br /> a ' ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> i 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: S/QC°A".7 I-A)6 Report for the onth of: 1/ year <br /> Company Address: 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) RESIDENTIAL NAME OF TREATMENT <br /> PUMPED PROPERTY OWNERPUMPED GR EASE TRAP___) FACIA-I-�Y <br /> = - <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY (C) CHEMICAL <br /> City ST / SUJ 15 <br /> elzl l cit <br /> EL"' Z-'17 • 1-719 Cr�S/' �nrn�Fir2 ✓� city <br /> d AMM' s-ld' Ll/ cit l /SVJ , t_ <br /> ,N-aV /41 .9 7 to 1n15V7ey 2,9wz cit ,t <br /> Agc NW ''70.;1, /d�2(�T/flG/1fi LSO,y Gt/��1 city 11 52)d <br /> C�77� 4 ��//'S IN�.J�/�Y1�m �16✓ City / ✓�`U 1 t /l <br /> cit t ( '>j1JV 0 ► ► I 1 <br /> 1 D <br /> &1*m 'Oukj awt Cit <br /> cit <br /> /1'I(DA-LI - -1 Gtl• /n" c cit <br /> % r'rVeA,7W- - Cit <br /> .!'' 3 'lt/f��s�/�� -r��1'/`��^L,/�.gs✓� Cit <br /> Cit / /��U /L I <br /> /kilo Zocv /JS"od 7/L%�/!T , 4AWr� City <br /> /'/t cit j/ .5719 t t s J <br /> City <br /> Page of <br /> EHD 42-04 SEPTAGE CLEANERS REPORT <br /> 12/27/13 <br />