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m <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> Return this form by the <br /> w a`" 3"e!e 1866 East Hazelton Avenue, Stockton, CA 95205-6232 12"' of each month <br /> (D ^`r Axa'' phone: 209 468-3420 Fax: (209) 464-0`!38 Web:www.sjgov.org/ehd <br /> n <br /> io SEPTAGE CLEANEWS REPORT <br /> Company Name: j.P--� <br /> d�'/4 J�S e <br /> _ Report for them_ � <br /> th 9f'. atcCmmpany address: ;70/ 4- yea r_?O <br /> oC �sveefAoraSs city Signature: 2f 4. <br /> /s <br /> Zip Code <br /> All information submitted must be com lete, acclzrate and legible <br /> DATE NAME OF BUSINESS OR <br /> PUMPED PROPERTY OWNER ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDEN7IAL <br /> PLEASE INCLUDE STREET N DIRECTION, STREET NAAfE AND CITY (G) GREASE TRAP NAME OF TREATMENT <br /> Z ' O G / PUMPED lCj CHEMICAL FACILITY <br /> �+ R Oth�i 4 of / Y ✓'( Ci •c IC/0 7 3 IS_ <br /> WVG �C b r �Y•r �r� S Ci i _ f/ O <br /> �T �Qr y Y ,� br�O �C�'r�lr LCOS /�� C ily ✓ci 4a 3 i <br /> a_ r P41C <br /> Cit y _ <br /> Qd ' /'•,mo v. Cil O i <br /> Ci <br /> Cil <br /> Cil o <br /> z <br /> Cil <br /> r` <br /> V Cit m <br /> m C-14 <br /> v <br /> N C� <br /> u-) Lc, <br /> m <br /> m <br /> Cy Cil o <br /> t <br /> n <br /> cn <br /> cV <br /> � Q <br /> m Cil <br /> LL) <br /> I— <br /> m <br /> N —a <br /> Page of <br /> CD EHD 42-04 — <br /> f 2/27113 <br /> CD SEPTAGE CLEANERS REPORTCI— <br /> a <br />■%%%\� <br />