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0..,aultr, <br /> 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 �2 of each month <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: �L; < C <br /> 2 fG?lG Report for th nth of: <br /> Company Address: ,/.j� '� � year (/ <br /> Street Address l ) 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 GALLONS (R RESIDENTIAL <br /> PLEASE INCLUDE STREET # DIRECTION, STREET NAME AND CITY NAME OF TREATMENT <br /> PUMPED G) oREASETRAP <br /> CHEMICAL FACILITY <br /> l <br /> cit <br /> a��✓� �/ //!� �J�UL3 Cit <br /> !lwVe City. �� <br /> Cit �� <br /> � � V t�RT� ✓a/� T <br /> cit <br /> 130 x U 'P%-t.rwYj'1 ;l cit >1 <br /> &b0All3lD s 1 <br /> �3 Gfl�i� aCity <br /> 120 �� 1i� �- <br /> � Cit <br /> cat Uva <br /> Cit <br /> sK Cit r <br /> ill, 7- <br /> city <br /> 7 GUS VS / T cit j' (111 <br /> q Q� 111 46E 7— cit <br /> City J <br /> Cit <br /> EHD 42-04 Page of_, <br /> 12/27/13 <br /> SEPTAGE CLEANERS REPORT <br />