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SAN JOAQUIN COUNTY <br /> "! ENVIRONMENTAL HEALTH DEPARTMENT Return this.form by the <br /> 1868'East Hazelton Avenue, Stockton,CA 95205-6232 <br /> Telephone:(209)'468-3420 Fax:(209)464-0138 Web:;,wwW.Sjgov.orglehd 12t" of each month <br /> SEPTAGE CLEA,eNER'S REPORT <br /> Company Name: ) I A Uw0r2//11C� L ,4.5'/�C i�/l <br /> Report for the month of: mac°/ years'/ <br /> Company Address: - __-?`�' . <br /> stmelnadress �� Signature: 1D �il� <br /> Cit' Zip Code <br /> Ail Information submitted must-be com fete accurate and le Ible <br /> DATE NAME•OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENflAL NAME OF TREATMENT. <br /> PUMPED PROPERTY OWNER PUMPED (8) GREASE TRA FACILITY <br /> PLEASE INCLUDE STREET A DIRECTION STREET NAME AND CITY Ct{E(JRCA7= <br /> city i 1JU <br /> city i <br /> uw 1�/�l✓ 75 GL S���irrli%� city 0 7< < <br /> luta 1l 1 /YI ot''17 l v�d 1� Ul i i"%,� cit / I 3 U(l) <br /> 9c i i <br /> 23 ,� G a s Ery li%t city <br /> fiv/�N ;S <br /> /(-?() US, i1I%c �YK cit <br /> Xboovl�-CC,OS /3 6 U % -,�r— city <br /> 'w' n T q 3 J UJ ia 7,4 i TF �74C city <br /> r2 2G i1 �U � rLS % cn 1 1 �7JiJ <br /> city <br /> ✓tel � a� 7S LiJ��T U/ " i i` ci J �• tJl9l� <br /> a � /u-�I�-v 'c3 n c�� � i y�� - i G •T� � � l <br /> �S <br /> cel a/ S <br /> -4)1'741'7 v&II T o(/ <br /> cit <br /> w- <br /> EHO <br /> I i <br /> Tt'/ NJ cit <br /> ci 7 1 � I i r <br /> Page of <br /> 42-0,4 - <br /> 12/27/13 <br /> SEPTAGE CLEANERS REPORT <br />