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' ►Rule, <br /> m. r <br /> g SAN JOAQUIN COUNTY <br /> _ ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA Return this form by the <br /> Il`ts� Telephone:(209) 468-3420 Fax: (209)464-0138 Web:.www.Sjgov.org/ehd 12t" of each month <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: ��� � v� L/�" .S'2e <br /> Company Address: /.> / <br /> -.F �� Report for the nth of: ear <br /> Street Address City Signature: <br /> City Zip Code � <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 DONE (R) _PESIDENTIAL <br /> PLEASE INCLUDE STREET # DIRECTION STREET NAME AND CITY GALLONS —� NAME OF TREATMENT <br /> PUMPED GREASE . <br /> D CHEMICAL FACILITY <br /> ............. city <br /> �� pq[Ja G1, (J� �;2 r r ; <br /> CIt 00 <br /> City <br /> City <br /> 222 l" ��' Cit <br /> Cit <br /> oZ l JU /7" <br /> pit <br /> a Cit <br /> cit I l�. <br /> Ci <br /> Cit ZZ W-1 <br /> C71 <br /> city 500 <br /> cit /! � <br /> cit 7 I ` <br /> Cit <br /> EHD 42-04 Page Of <br /> 12/27/13 <br /> SEPTAGE CLEANERS REPORT <br />