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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> < 1868 East Hazeito,n Avenue, StOCI<ton, CA 95205-6232 Return this form b <br /> Telephone: (209)468-3420 Fax:(209)464-0138 Web: y the <br /> WWw.sjgov.org/ehd 12t1' of each month <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: �/�,� ° <br /> Company Address: jStreeAddress13 - Report for e Un <br /> onth of: 1� yea r:�J/ <br /> t Signature; <br /> All information submitted must be 11,01111tZIP Code tete accurate and le Ible <br /> DATE NAME OF BUSINESS OR <br /> PUMPED PROPERTY OWNER ADDRESS WHERE WORK WAS DONE <br /> PLEASE INCLUDE STREET # DIRECTION STREET NAME AND CITY GALLONS �R; RESIDENTIAL <br /> PUMPED GREASE NAME OF TREATMENT <br /> O CHEMICAL FACILITY <br /> .�a//4 CA �,4�/ cit :�T 'JAZ 7-6/l/ /�'60' <br /> � Cit <br /> Cit" <br /> LrJv c / i <br /> Cit <br /> / C t � r <br /> rl�dli/19l(�f City <br /> Cit <br /> 08 Gt/�F�/t(�jv <br /> City <br /> 676), <br /> Cit <br /> City <br /> Y, / <br /> at <br /> Cit <br /> rnef4'� cit <br /> 10"7 ! l <br /> cit j 1 J l r <br /> a <br /> 4 / /7 �rsT� bllr<IOIES Cit <br /> /78 <br /> CI �� G LL nryn C <br /> EHD 42-04 <br /> 12!27/13 <br /> Page of <br /> SEPTAGE CLEANERS REPORT <br />