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�.e�'af• SAN JOAQUIN COUNTY <br /> q; 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)464-0136 Web.-,..www.sjgov.org/ehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: ll G. wUe 114 - GIM ,VAG Report for the,month of:A0141zfr year <br /> Company Address: �/3. �/�� � _ . i�/? I _7.7_J ,�i Signature: <br /> Street Address city Zip Code <br /> All Information submitted must-be complete, accurate and legible <br /> DATE NAWOF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RE ENTIAL NAME OF TREATMENT. <br /> GREASE <br /> PUMPED PROPERTY OWNER PUMPED TRAP FACILITY <br /> PLEASE INCLUDE STREET a DIRECTION STREET NAME AND CITY CHEMICAL <br /> ly / /fit/ ivt/ ST /7L citv <br /> 'ri9ZFL <br /> ;?NO /rl L12— f 9f cityC7�U i <br /> e "' U�S'�-C ' go W'F'S7-mss e114C%E xw9-6 cit d� <br /> oa& 29� *,tSL cit <br /> �CP0110 A eti � <br /> 1 -/5//7 c)Oi TZI& (009,,-- 1 907J ' city (yC) /. L) <br /> cu <br /> city <br /> city <br /> cit <br /> city <br /> city <br /> city <br /> City <br /> cit <br /> c1tv <br /> Page of <br /> EHD SEPTAGE CLEANERS REPORT <br /> �zrz7113 na <br />