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Qr,,4 R I, <br /> r_ ? SAN.JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209)468-3420 Fax: (209)464-0138 Web: Return this form by the <br /> www.sjgov.org/ehd 12t" of each month <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: / y <br /> Company Address: Report for th nth of-�r cC� <br /> year o2--�2 <br /> Street Address Signature: U. <br /> city Zip Code L/ <br /> All Information submitted must be com tete. accurate, and legible <br /> DATE NAME OF BUSINESS OR <br /> PUMPED PROPERTY OWNER ADDRESS WHERE WORK WAS DONEIR E IDENTIAL <br /> 7a� G GREASE TRAP_ <br /> PLEASE INCLUDE STREET # DIRECTION STREET GALLONS NAME OF TREATMENT <br /> NAME AND CITY/ PUMPED • <br /> C CHEMICAL FACILITY <br /> L9 <br /> //r / <br /> cit /� 7C. <br /> UJ if <br /> yasS-rnv p <br /> City1 <br /> Pat/ C0 N§j 0 `,>/ - r i Cit r <br /> City <br /> 53�`Ei3Si <br /> C' <br /> City <br /> - City <br /> Cit <br /> �%e�� �• Cit <br /> Cit <br /> cit J r <br /> e-7o �. ell 4�z �� I <br /> � <br /> d <br /> City <br /> yG' Rl'-4 �- cit <br /> cIt 5�L <br /> EHo 42-04 <br /> Page <br /> 12/27/13/13 <br /> SEPTAGE CLEANERS REPORT <br />