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Qr,4kl!{ o <br /> z< �� SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Return this form by the <br /> }10. 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: <br /> Report for the,month of. ear o7�/ <br /> Company Address: ,/�jj �f � f� �Q _ 7 <br /> Street Address cic Signature: <br /> y Zip Code <br /> All information submitted must be com tete accurate, and legible <br /> DATE NAME BUSINESS OR S WHERE WORK WAS DONE GALLONS <br /> PUMPED PROPERTY <br /> ADDRESS OWNER (R) RESIDENTIAL <br /> PLEASE INCLUDE STREET # DIRECTION, STREET NAME AND CITY PUMPED ) GREASE NAME OF TREATMENT <br /> C CHEMICAL FACILITY <br /> Lc r7IYI /0 (� cST <br /> C , <br /> S /3a0 AGS ' Cit <br /> Cit <br /> a U �% C it �i <br /> Cit 1f 1 <br /> 3i� y <br /> cit <br /> Cit <br /> Cit <br /> Cit / l <br /> CityL`Ud <br /> I3/ �- <br /> G/2 cit 2� vE <br /> S -25- <br /> Cit $% �• <br /> a✓al-Otii�x <br /> cit <br /> Cityi SZd l <br /> s 13 L onJ <br /> City /( <br /> 'A) P <br /> Cit City <br /> l( i QJcJ I <br /> i � <br /> EHD 42-04 Page of. <br /> 12/27/13 <br /> SEPTAGE CLEANERS REPORT <br />