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SAN JOAQUIN COUNTY <br /> n� ENVIRONMENTAL HEALTH DEPARTMENT Return this.form by the <br /> 1868 East Hazelton Avenue, Stockton,CA 95205-6232 10i of'each month <br /> Telephone:(209)468-3420 Fax: (209)464-0138 Web.;..www.Sjgov.org/ehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: G / C S'2e L i�/l% Report for the=th yearCompany Address: 1�.>. �r�� 'elr ,�� /� (�,¢ S Signature: � <br /> Street Address city Zip Code <br /> All information submitted must•be com Tete accurate and legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONEGALLONS (R) RESIDENTIAL NAME OF TREATMENT. <br /> PUMPED PROPERTY OWNER PUMPEDIST GREASE TRAP FACILITY <br /> PLEASE INCLUDE STREET 8 DIRECTION STREET NAME AND CITY CAL <br /> ci D Li S �� <br /> r <br /> i)/L city <br /> lea ,mow wvd city. ac <br /> CM IC-J—A. 32 cit l <br /> QV— <br /> IW.,?-/�Lll�l►tp o `� /YJ��, _ A_ / Clt (J <br /> �,f�l�/✓� i�0 .�S ���7Y�/(/n �YDI/� Cit <br /> city <br /> •3 vv <br /> c�50 �• /J'1 4- cit / <br /> 1)cyw %` i�E'l city 8 SU <br /> %N� G <br /> city3 Ove <br /> cit <br /> of <br /> ty <br /> �,0 <br /> city <br /> /"447 f pav cit / l SGS <br /> D,6-170 GvrT YhA-.0 14 CXn/.�4—` cit 3 � <br /> So d <br /> Page of S` <br /> EHD 42-04 <br /> 12/27/13 SEPTAGE CLEANERS REPORT <br />