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0�t <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 12 of each month <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: � I �s . <br /> tl�'%- <br /> Report for t onth of:Company Address: �j '' year�lJi7Street Address � Signature, <br /> City Zip Code <br /> All information submitted must be com lete, accurate, and legible <br /> DATE NAME OF BUSINESS OR <br /> PUMPED PROPERTY OWNER ADDRESS WHERE WORK WAS DONE GALLONS (R) Rl ............................NTIAL <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME qND CITY NAME OF TREATMENT <br /> PUMPED GREASET FACILITY <br /> C CHEMICAL <br /> � Cit <br /> mac✓ <br /> � 0 cit <br /> Ua o CS. ' i/ S 1/ - <br /> city. <br /> "v Cit), �l /6?6 <br /> Cit �l <br /> JU IT Cit ?/ <br /> I G ; <br /> Cityi av <br /> �Z c <br /> FG T��o . 5'936UD J � 19�v� pit i <br /> 3 504, <br /> City ' \ <br /> cit <br /> Cit <br /> G Po X/0 zc& <br /> i-�8�ib T � <br /> City <br /> c cit %I <br /> 7 �p Tser� �� �o�� Cit <br /> l >�L <br /> EHD 42-04 Page,��,a <br /> 12/27/13 <br /> SEPTAGE CLEANERS REPORT <br />