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RECEIVED SANJOAQUIN COUNTY <br /> Return this form by the <br /> -,I HEALTH DEPARTMENT <br /> ENIVIRON1 <br /> 600 East Mah Street, Stockton, CA 95202-3029 73 th ach month <br /> 'felephcma: (20e, 468-3420 Pax., (209)464-0138 Web:YAvN.Sjgc-v. <br /> JAN 0 6 2011 <br /> ENVIRONMENTAL HEALTH SEPTAGE CLEANER'S REPORT <br /> PERMIrE5MES <br /> Company ame: , j t <br /> v t Roportforlhamonthoar: Z <br /> Company AddrE-as: la CA 9340 Signaiurc-: A.I <br /> Svee.0.dC es5 Y -71—PC71-1 U/ <br /> All 1,forInatlo.11 GuI�MIM!d roust be cbrnploto, accurate, and 1.tRl.blo <br /> -XIA <br /> AUDRESS W14ERE WORN WAS DOMF GALLONS (11) RESIM L NAME OF TREATMENT <br /> DATE NAME OF BUSINESS OR FUNIPLO P)l GREASE TRAP FACILITY <br /> Fuiwppm Pr%opL.p'fY OWNER Rn Cl,ryII <br /> ; PLBASE INCLUDE. STREET DIRECTION, STREET NAVE A <br /> J <br /> ON, <br /> -_ 1 - _. _ -_- _�. <br /> In <br /> -�- <br /> L <br /> (L cit, • <br /> T_.. <br /> E <br /> ----------- <br /> c <br /> 0 City <br /> LLJ <br /> 0 <br /> O <br /> SF-::TA3EII5 R��C:+T <br /> 42-4 <br /> ICA,107 <br />