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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> ry 1868 East Hazelton Avenue, Stockton, CA 95205-6232 12th of each month <br /> Telephone:(209) 468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: `Toy1 f !Z S, Lyc r Report for the montho JAS _ year . U <br /> _ ) Lam, C� <br /> Company Address: �� nr l C l/ t'c a' ce. 5'y3oy Signature: <br /> Street Address city 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 NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED (G) GREASE TRAP FACILITY <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY C CHEMICAL <br /> Liu Stpft_ &019rs Cgjat AVP city Tr4,.c 000 NN I �C <br /> S ' L VC, 31qb City Tr4 Y aoo© R ra <br /> 3 O S H a 6 50 AUA0114,r ©r, Ci ra L y 000 R Tr4 L <br /> 3 Ali 311115 S8ir <br /> 3 1Lls T ; F-,-&) r6,nks Rd city T <br /> nr /0,00 8 Tri <br /> 7 9 ,✓ Ev rr V Pcity Tr& ey 10 7'jea e <br /> 8 61 kh1 r 3406 krh?t? tcity I& er two rt <br /> �' city -A Kta 100e ra G <br /> ' b h Y Eadr 3-gi av kasOA R City z/e t� 1Df00 R c et _ <br /> D r l I S < /! Ci ^ r- loop 4 <br /> 10 51 w Dr I city Tige y /we <br /> lea I rr y t Ci 1-3a h0 R Trqek <br /> I <br /> SI, t PA W, 13 c <br /> 1 R Y r l C,-/. city /to IfG <br /> 1642fid&S L0 75 MccAdI.4 if Die --- city TA4-r .1 /6d o l3 Tr e <br /> cityL <br /> rArt R city �, �. Joan R 1q el <br /> 1. 31 L V 1 �ti Y�Is+ k Ci -r,,° �' !I9lie t? ..,,� • <br /> EHD 42-04 <br /> 10/4!07 SEPTAGE CLEANERS REPORT <br />