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SAN JOAQUIN CUUNTY <br /> q, ENVIRONMENTAL HEALTH DEPARTMENT Return thisform by the <br /> ti 1868 East Hazelton Avenue, Stockton, CA 95205-6232 12tH of'each month <br /> r Telephone:(209)'468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: G 1 C ,S'/�CG 104i"LyeReport for the month of: ? year -'-'R0/ <br /> Company Address, ,�3 ; � Signature: <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 eREASETRAP FACILITY <br /> PLEASE INCLUDE STREET # DIRECTION STREET NAME AND CITY CHEMICA <br /> A Ci <br /> S cit �ave <br /> R*1 Wll / L'b0Z oq GU lv"Me'4 ��' cit <br /> ' cit 5 <br /> 5n,21JD f 4 cityS <br /> cit <br /> �i'L UitJ <br /> City / <br /> Bel/ s 6�S"s. <br /> gyp✓ � 1 city <br /> Cit i <br /> ci <br /> ��G>rZi�JriJ"( Gr7D ✓� v0 .S'��fi> <br /> city a OLD <br /> e oo✓r4 IF,U /0. 3 sLl i✓i�� 0� cit <br /> cit <br /> city z/0 <br /> 6 94 <br /> Page of <br /> EHD 42-04 <br /> 12/27/13 SEPTAGE CLEANERS REPORT <br />