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RECEIVED <br /> SEP 13 2017 <br /> SAN JOAQUINCOUNTY ENVIRONMENTAL HEALTH <br /> PERMIT/SERVICES <br /> 44 t. ENVIRONMENTAL HEALTH DEPARTMENT Return this.form by the <br /> ti 1868 EastHazeltgn Avenue, Stockton, CA 95205-6232 12tH of'each month <br /> f Telephone:(209)'468-3420 Fax:(209)464-0138 Web:,www.sjgov.org/ehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: G Smvmikln /�4'm1��r21/t1Ci & �A�2C p "Az Report for th m nth of:Aad% year <br /> Company Address: /�3 r�' � r_ . "� L1Tl) ,(� "� 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 fR) RESIDENTIAL NAME OF TREATMENT. <br /> PUMPED PROPERTY OWNER PUMPED GREASRTRAP FACILITY <br /> PLEASE INCLUDE STREET # DIRECTION STREET NAME AND CLTY C CHEMICAL <br /> city <br /> 051 L u 77 9 o,9-0 city, 1 <br /> oZ A �i 'S l(053 170/1 G/YviJ kWV city 1""5 ' <br /> �//. I �Zv Sit <br /> /S N4- Ciw d ` l <br /> 6 O Al e cit <br /> CJS 110 city <br /> C It <br /> -;4;VAI /L 2",5 .QST e l-1t/, city /f^ �l <br /> city /C <br /> cl / <br /> Cit <br /> 61tv <br /> Page Jof <br /> EHD 42-04 <br /> 12127M3 SEPTAGE CLEANERS REPORT <br />