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u + <br /> RECEIVED <br /> MAY 13 2014 SAN.JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> > Return this form by the <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> 12t�' of each month <br /> r ENVIRONMENTAL HEALTH Telephone:(209)468-3420 Fax:(209)464-0138 Wei ww%v.sjgov.org/ehd <br /> PERMIT/SERVICES <br /> o SEPTAGE CLEANER'S REPORT <br /> Company Name: i`1.1'I rn) r t <br /> t Report for the month of: � year <br /> Company Address: i >—C { IS fl9' - ;'; ` I5 ;. ., ,mature: <br /> Street Address City Zip Code <br /> All information submit[®- must be co,mP tote, accurate, and le ible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAL NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED (G) GREASE TRAP FACILITY <br /> PLEASE 3! <br /> .SE INCLUDE STREET , DIRE GTIO N, STREET NAME ANq CITY C CHEMICAL <br /> 1 - citY ;tft. C- - ,J <br /> P— t� -- <br /> Ci <br /> t i C-5 1 %t 10' F t bv-65 cn <br /> city <br /> ro nv <br /> bk I'f J A � Cit - <br /> `V <br /> rt. <br /> �,�,-t�. :,-c� <br /> i n City k { . <br /> O I D i-'t/l i'1�. .� city <br /> o .f ) GttC (� L1tGt �rYn: T 3 <br /> N 4 Ci <br /> (t '�� L'i ^^•�' ( ti Y'\. 1''air•.y.f"T Cit fLt-- AA`-'"-il.-- Imo-- 1 �-�.i..'�(: �✓�I W.��' o <br /> cityI t 44/< c, <br /> 1 LJ ice- Vii C fk��:� c-, <br /> { ►1 t?{= 'Lj %rblr't'. i C�2 "'r Rw 7 f �.� cn <br /> cI f520 !3W O <br /> M"Cok-t <br /> cit .. (lLt <br /> I Y(lli l+L(iriil(� _ `+y 5j 6,I Cil ;rte . 901 <br /> t E ! t - -- U _ <br /> city <br /> o � Pl\tl 5561� city <br /> N <br /> 0 � <br /> to -— <br /> d 42-04 <br /> 10)4/07 SEPTAGE CLEANERS REPORT a� <br /> 1014 <br /> 0 <br /> F E <br />