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a <br /> s4 >F SAN 3OAQULN COUNTY <br /> ENVIRONMENTAL HF-ALTH DEPARTMENT Return this form by the <br /> 1866 East ijazelton Avenge, Stockton, CA 95205.6232 'i 2�'' of each month <br /> f, <br /> rt, - Telephone:{209}468-3420 Fax:(209) 464-0138 Vi/eb:wruv.stgov.orglehd <br /> . 1SEPTAG CLEANER'S REPAORT (�kL— <br /> ;Company [tName: � - <br /> Repofor the h of: yeaa � <br /> -. -----� <br /> Company Address: Signa <br /> Sheet Address <br /> city Zip Code <br /> All information Submitted mllSt be complete. accurate, and legible <br /> GALLONS (R) GREASE TRA NAME OF TREATMENT- <br /> DATE NAME OF BUSINESS OR ADDRESSVdiiERE WORK WAS DONE PUMPED {G) GREASE TRAP FACILITY <br /> PUMPED PROPERTY OWNER PLEASE INCLUDF STREET 9, DIRECTION, STREET NANE AND CITY {C} CHEWCAL <br /> A) T� <br /> CI< �- I <br /> c� U <br /> C 4 <br /> ftV <br /> Cit <br /> 1 t(g ' CRV <br /> ` ! Cit' K `` m <br /> Lk, <br /> C"14 o 4 0 <br /> 0 <br /> Q <br /> Ci r` <br /> G� <br /> 0 <br /> 16 <br /> o <br /> Page of <br /> a, <br /> SEPTAGE CLEANERS REPORT — <br /> EHD 42-94 u <br /> 12127113 <br /> r�— <br />