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.qul"y <br /> �0.e.c�goti. 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:vwwv.sigov.org/ehd 12 of each month <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: I( ,, )- L <br /> � �411G �i <br /> ,�� G.,�� Report for the month of: year,--AL) /;7 <br /> / <br /> CompanyAddress: f ��� �� <br /> Street Address � Signature: <br /> City Zip Code <br /> All information submitted must be com tete accurate, and legible <br /> DATE NAME PE BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RE NIt�L <br /> PUMPED PROPERTY OWNER NAME OF TREATMENT <br /> PLEASE INCLUDE STREET # DIRECTION, STREET NAMEAND CITY PUMPED GREASE TRAPi <br /> C CH FACILITY <br /> city %lI 4a -S9 <br /> Cit � t jl <br /> -%s /UdD S- /i�/l /lam' li <br /> cit <br /> I cit L) >/ <br /> Ci!y P <br /> cit <br /> v� cit <br /> s'I'7&i Clv cit 9 _ l <br /> Cit <br /> Ia �/ cit <br /> cit <br /> cit <br /> Cit <br /> Cit t11� 1 <br /> Cit /Sd C <br /> EHD 42-04 Page Of <br /> 12/27/13 <br /> SEPTAGE CLEANERS REPORT <br />