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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Return this form by the <br /> 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: ' ) � ��� <br /> Report for;thZthnof: M Company Address: �j ryeara� <br /> Street Address Signature: <br /> City Zip Code <br /> All information submitted must be complete, accurate, and le ible <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 GREASETRAP NAME OF TREATMENT <br /> PUMPED� EMICAL FACILITY� r <br /> CH <br /> +r�iviL ir/ i Cit � 0� /�'Gcl S,i G1�� — <br /> 7,/ Cit I� ✓G'U >c 1 <br /> City. <br /> cit II � <br /> zd 60 106-0h 71-2J <br /> Cit <br /> lrtliAlc a <br /> ftp esi 0 8 Cit 1 I <br /> L& IL r I <br /> Cit/5 // C it <br /> 7641<)d /0;1,0 (< a <br /> U�it 1 l C <br /> cA <br /> k/9 A I&Ar/V k7' <br /> c c / <br /> Cit l) S <br /> i ,fid� <br /> City <br /> /3 s�lfcr o nein k7. Citi <br /> /Oa C s e�� sT <br /> Cit <br /> EHo 42-04 Page of <br /> 12/27/13 <br /> SEPTAGE CLEANERS REPORT <br />