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RECE Ib <br /> a°4 SAN JOAQUIN COUNTY <br /> JAN 03 2017 ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 12th of each month <br /> RONMENrA- Telephone: (209)468-3420 Fax: (209) 464-0138 Web:www.sjgov.org/ehd <br /> ►ate PF-MRln.?ER41cm -- <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: $�Ani/QRurw )n <br /> � � 9 Report for the month of: 1')-L year 2014 <br /> I <br /> Company Address: _ �3 1 ne,— ?J TL4-tocL CA <br /> Signature: <br /> LID Street Address City Zi Code <br /> r� P �ooju 0j <br /> cfl All information submitted must be complete, accurate, and legible <br /> � <br /> DATE NAME OF BUSINESS OR (R) RESIDENTIAL <br /> o PUMPED PROPERTY OWNER ADDRESS WHERE WORK WAS DONE GALLONS (G) GREASE TRAP NAME OF TREATMENT <br /> N PLEASE INCLUDE STREET tl DIRECTION, STREET NAME AND CITY PUMPED C CHEMICAL FACILITY <br /> CRY <br /> Cfty <br /> cit <br /> / cit <br /> _. N6 City <br /> City <br /> City <br /> -- o <br /> CRYo <br /> citv <br /> m <br /> Q gly <br /> o <br /> n cit <br /> � o <br /> -- City <br /> -- C <br /> U) <br /> City <br /> C <br /> o C ~ <br /> N " � <br /> OL=L== <br /> C11 <br /> a, <br /> Page of <br /> O <br /> c <br /> :EX ■Y�4 304 SEPTAGE CLEANERS REPORT <br />