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�W c�ti 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: (2.09)464-0138 Web:www.sjgov.org/ehd 12 of each month <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: �y ���. � 1 .� <br /> Company Address: � z- Report for the month of: yearoZ-7 <br /> Street Address City - Signature; �r., <br /> Zip Code <br /> All information submitted must be Complete, accurate, and legible <br /> DATE NAME OF BUSINESS OR <br /> PUMPED PROPERTY OWNER ADDRESS WHERE WORK WAS DONE GALLONS T11 _RESIDENTIAL <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY GREASE NAME OF TREATMENT <br /> �c_ PUMPED FACILITY <br /> ` I T z /� C CHEMICAL <br /> ((/ 4 n )�; ��� Cit c `v a S G�JC� <br /> � � �' if Cit 15?) � . < < <br /> City W 1 I G <br /> sC�DI/ 1-/`711-7 /��� �,ST <br /> Cit <br /> v 1 t t <br /> �C lr7s't; cit / v �� <br /> City <br /> ?9AOGYJ <br /> 1 G>1/ .� <br /> �t-fuLT G� y (� <br /> r//I -R;? 06 AlviTi4 .(/A---,Gv�o cit <br /> at �( <br /> 1�51)� <br /> City <br /> r orb /L <br /> a <br /> �?z/3 A44-0 cit ( I <br /> cit <br /> d .3 (ZL&L ,n <br /> City_ L <br /> a <br /> city <br /> /wrJ Q 'n cit L <br /> / ,'YY� <br /> EHD 42-04 Page ?_Of�_ <br /> 12/27/13 <br /> SEPTAGE CLEANERS REPORT <br />