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0 <br /> JAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT / <br /> Return this form by the <br /> 4 1868 East Hazelton Avenue, Stockton, CA 95205-6232 12th of <br /> each month o <br /> ���L ¢f Telephone:(209)468-3420 Fax;(209)464-0138 Web:www.sjg0v.org/ehd <br /> SEPTAGE CLEANER'S REPORT w <br /> Company Name: <br /> C <br /> Company Address: t Report for the month of: �'1`�t��rclrk. y <br /> -a ear <br /> SlreetAddress ��City Signature: <br /> Zip Code <br /> All information submitted must be co m tete, accurate, and le ible <br /> DATE NAME OF BUSINESS OR <br /> _ PUMPED PROPERTY OWNER ADDRESS WHERE WORK WAS DONE <br /> oGALLONS (R) RESIDENT)AL NAME OF TREATMENT <br /> PLEASE INCLUDE STREET 1j. , DIRECTION, STREET NAME AND CITY <br /> PUMPED tG) GREASE TRAP <br /> {�C-1 G ! t�Cp`{ Y� f) C L FACILITY <br /> f _.� CHEMICAL <br /> cityr rvaL <br /> - ;,�,6 dd - <br /> 'i <br /> Irl y v� n 1 <br /> city nka9t t r'1k ce,.. frl,.6?C, <br /> w `} D � ttC° <br /> cit �'E�L�{.YL 'L F'f'�. •1 rfLG ea_ C 1' 0 <br /> IS i <br /> f , <br /> City i�U�°�.�' 1��:' �. ,� s <br /> 57 7Sa <br /> l <br /> Cci <br /> �a C-,-3f �- ri <br /> QC <br /> City <br /> c <br /> Ci <br /> Ciry o <br /> 3 <br /> EHD 42-04 x <br /> 1014/07 i7 <br /> SEPTAGE CLEANERS REPORT <br /> m <br /> C <br /> cD <br />