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rg41y' SAN JOAQUIN COUNTY <br /> �°o,1ra Citi <br /> z ` ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 12t" of each month <br /> ;•- ;a a Telephone: (209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: ,7,?(! Report for the month of: �B ��' year <br /> Company Address: / �``�� /, �;G� 13/- sl*1�4 lwlo CfPl 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 OWNER PUMPED GREASETRAP FACILITY <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY �-; (C) CHEMICAL <br /> �/� �Sy C `CG °�✓� Cit L) Qr/� ���✓�IfS.S <br /> Cit r� 1 <br /> ROD Roe) 2-)7 D A f City <br /> �IQV L) cit i( r r <br /> �2 5v Saint/ 8 Cit i <br /> / t'�vsi�GflltvCEs�c� / �&� W651 :R- ucT A Cit / L/citlJ t I <br /> %DS%fid 1�ll CES�L� <br /> 7<996 /fIWi/taLTE XwW Cit lJU ' i <br /> wT City If /UCS t <br /> oa k 6 L)j2va/L 30-5-7 Ku,+o Cit <br /> !<,�c�� �vYcrri tier Z Z� Cit �-� <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> City <br /> Cit <br /> Cit <br /> Page 37 of <br /> EHD 42-04 SEPTAGE CLEANERS REPORT <br /> 12/27/13 <br />