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°f'4ultt' O SAN .JOAQUIN COUNTY <br /> r_ ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 12th of each month <br /> Telephone: (209) 468-3420 Fax: (209) 464-0138 Web:www.sjgov.org/ehd <br /> SEPTAOE CLEANER'S REPORT <br /> Company Name: s �r 7�. SHS ; /0" Report for th t— th of: WWII year c� <br /> Company Address: ���5a5�% TC�G� L'3C.S/,�Cf�� i7�`�J�, � � �i Signature: rii Al <br /> Street Address City Zip Code <br /> All information submitted must be complete, accurate, and le able <br /> DATE NAME OF BUSINESS 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 p, DIRECTION, STREET NAME AND CITY (C) CHEMICAL <br /> / <br /> Ai4l 6 1/lJ r/ L� cit <br /> Clt I /[ <br /> d0% �9f�% _m� � / AWY--!iP—A)oL cS.i city ! / o`�S� •c r r <br /> L a`�a0 cit <br /> �1 /�IL',vJr✓ c?I /3 /Q,t1� cit I •/ <br /> cit <br /> c tiJlf d s — Cit t 571J t l <br /> d oS cit <br /> IR Cit <br /> J0, / .St1 s_ Cit <br /> L //0 to eD / 3 0 ' yoJjlni%F City 4 S?/d r t l <br /> S/1 1101k &ZWA6i� z yo d• % Cit ( 61d <br /> 17 cit I t U [ I <br /> off(/ G JaD� /WiAtJ <br /> City It <br /> cit > ' /--70cj <br /> Page_ of <br /> EHD 42-04 SEPTAGE CLEANERS REPORT <br /> 12/27/13 <br />