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Qr.4ul.ry, o <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this fot -n by the <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 12t1' 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: . iu(9 SRR A mai Report for the i nth of: 7year a d I S— <br /> Company Address: 6-; 'g Signature: / X <br /> Street Address City Zip Code <br /> All information submitted must be complete, accurate, and legible <br /> DATE NAME OF BUS114ESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAL NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED G) GREASE TRAP FACILITY <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY ` (C) CHEMICAL <br /> s/"// ` S a L 4i7f ;J �j% Cit OU ✓vJ �� V�/C <br /> �J /4 7 SIJ Cit <br /> .R'Y3 1'11is%111 ./ !�/✓✓c city C c i.SO v c it <br /> %/'le�(�/ �:5 /v�J d✓�6L�/`f C'�i`C.s c��c/ GU Cit <br /> /57 LaA/ J 5-0335-6LI4! - 9�1'/15',,�iro � cit // c/ wo E'*Xv <br /> a D %Go 3,611ais��i/��1C°/7 [�7D1�� Cit <br /> Z3 691z CC _ r - Cit <br /> P ` s' errs Cit <br /> Cit i 1 ` eT�lJ 1 r <br /> aN Wjj,:=NegSCN,,j 799 5 phiIt 4W L4 '7 1 City I1 svJ "go vvE4X <br /> a - uT8 .-2 X, XWe/I/ City i sd S� GAJ <br /> L' U i�tl i <br /> ?,,M AIV,9--t1l cit / I £J t • t <br /> a Spsi a�a� i r�/t�J L7— Cit .rOtl l I t I <br /> A7 1 2f S P;y iS- A :- cit / asp 9,0, C5- <br /> city 1p - <br /> _ Cit <br /> pit i 1 �• �r� t t I <br /> 1 <br /> Page <br /> EHD 42-04 SEPTAGE CLEANERS REPORT <br /> 12/27/13 <br />