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►�ult�, <br /> z' SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Return this form by the <br /> trca�+ Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd 12 of each month <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: ¢� � <br /> �G 2� Report for the month of: J bAJ r' <br /> Company Address: �3��C/�'���� � _ ear <br /> Street Address city Signature: <br /> Ail information submitted must be Com lete accurate and legible <br /> Zip Code <br /> DATE NAME OF BUSINESS OR <br /> PUMPED PROPERTY OWNER ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAL <br /> PLEASE INCLUDE STREET # DIRECTION STREET NAME AND CITY PUMPED GREASETRAP NAME OF TREATMENT <br /> CHEMICAL FACILITY <br /> G't'a GrI SS L' — tit/ C[tvC�l`t <br /> -- CIt \ <br /> cit >� <br /> c c <br /> �"' ►V/GZ7C��( City <br /> ��✓�.� Cit <br /> C �< /� � Cit' I I l l C I <br /> �J lE l aj� /iU/2 /� Cit <br /> RlQ o1 (a, <br /> l7z zc . c i <br /> UU�i l< <br /> /Da D ,� - C� ��i .� <br /> / at o?v <br /> �N� :S ��i fir, <br /> >�2e vLill �t} !��✓ c t I <br /> Cit <br /> 0 8 74)tiVi P"�c�c,1 Sad i c c <br /> s ( N Acrt / 3 fit)J l , i <br /> �31� � �`/i/✓ �S � r <br /> CityI l ,� �J✓) �Q(l� �/1 r(�I <br /> ,b 2 crt a,Vt) <br /> - <br /> EHD 42-04 Page — Df — <br /> 12/27/13 <br /> SEPTAGE CLEANERS REPORT <br />