Laserfiche WebLink
SAN JOAQtJIN COUNTY RECEIVE <br /> r. ENVIRONMENTAL HEALTH DEPARTMENT JUL 0 7 2014 Return this form by the <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 12th of each month <br /> a� Telephone: (209)468-3420 Fax:(209)464-0138 Web:www.sj90MW MENTAL HEALT <br /> SEPTAGE CLEANER'S REPORT PFRMIT/Sl=RVqC-ES <br /> Company Name: F u rlcy Report for the month of: SL4 yearilly <br /> G L� <br /> Company Address:_ 101-j Al;1 , ,^,t ,�,+ A g 4565 Signature: <br /> SireetAddress Crky Zip Code <br /> All Information submitted must be complete, accurate, and legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAL NAMEOF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED (G) GREASETRAP FACILITY <br /> PLEASE INCLUDE STREET R, DIRECTION STREET NAME AND CITY (C) CHEM]CAL <br /> 1-4,A Lr �sf ljt� stcity Trr DIMSS <br /> 3� C <br /> Citym— t- mil <br /> city T11-4-v $ b C L B MLA <br /> city <br /> citv0 <br /> 0 <br /> z <br /> city <br /> city <br /> CO <br /> CR <br /> 0 <br /> cityf <br /> Ci <br /> city <br /> C" E� <br /> t— <br /> city <br /> Page---- _ofd_ <br /> EHD 42-04 <br /> t2127N3 <br /> SEPTAGE CLEM+ERS REPORT <br />