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1-4 <br /> 4�, ECEIVED <br /> SAN JOAQUIN COUNTY <br /> m W ENVIRONMENTAL HEALTH DEPARTMENT <br /> AUG 10 2016 1868 East Hazelton Avenue Stockton, CA 95205-6232 Y Return this form b th e <br /> w x n6'at;` Telephone; (209)468-3420 Fax. W <br /> (209)464-0138 Web:vAW-sj90v.org/ehd 12th of each month <br /> i ENVIRONMENTAL HEALTH <br /> � <br /> PERMIT/SER/ICES - <br /> 1 SEPTAGE CLEANER'S REPORT <br /> Company Name: J' <br /> Company Address: "6oy�y�y Report for the month of:_/U year 4� <br /> Gz �� Signature: <br /> Street Address 053 ----' <br /> Zip Corte <br /> All information submitted must be com fete, accurate, and le Ible <br /> DATE NAME OF BUSINESS OR <br /> PUMPED PROPERTY OWNER ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIMMAL <br /> PLEASE fNCLUDE STREET A DIRECTION, STREET lJAIdE AND CITY PUMPED �G) GREASETRAP 4Af19EOFTREATMENT <br /> w ���,-I� FACILITY <br /> (Y C CIiEIACAL <br /> � � C <br /> <I ' <br /> LL1 <br /> � Cit <br /> co ti <br /> <-I <br /> 3 C ily <br /> Co <br /> Ld Cit <br /> <I - <br /> } Cit <br /> CR <br /> Ci <br /> Ci o0 <br /> 0 <br /> C' <br /> 0 <br /> Cit <br /> m r� <br /> LL Ci <br /> In C' T <br /> v I <br /> OD o <br /> O� <br /> CD cityo <br /> � cr <br /> CR ' <br /> _ o <br /> CO �. <br /> m t.0 <br /> �D Ci <br /> N <br /> ri q F- <br /> 0 <br /> 04 Page. of <br /> EHO Q-D4 > <br /> 92127143 — <br /> N <br /> m _ <br /> SEPTAGE CLEANERS REPORT <br />■ ■ ■ ■ ■ <br /> ■ 0 ■ ■ ■ <br />