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RECEIVEV <br /> JAN 0 5 SAN JQAQUIN COUNTY <br /> CD zO�J EWIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 600 East Main Street, Stockton, CA 95202-3025 <br /> w - ENPRRNMEIVTgL SIL Telephone: (209) 468-3420 Fax:(209)4640138 Web:www.s}gov.org/ hd 122'' of each month <br /> ` M►T/SERVI E <br /> w SEPTAGE CLEANER'S REPORT <br /> Company Name: �. <br /> Report for the nth of: year 52V7 V <br /> Company Address: Yl • C� ,� �c�y� y� �� L� <br /> Street Address crty Signature: <br /> Tip Cade <br /> All Information submitted roust bo'com fete, accurate and le Ib3e <br /> DATE NAME OF EUSIHESS OR ADDRESS WHERE WORK WAS DOME (R) RESLDENTLAL <br /> PUMPED PROPERTY OWNER GALLONS NAME OF TREATMENT <br /> PLEASE INCLUDE STREET 4, DIRECTIO?I, STREET NAME A1tD CITY PUMPED (G) GREASE TRAP FACILITY <br /> 1 C a�ouGa1. <br /> ry Ci <br /> w <br /> � C <br /> 3 <br /> w <br /> ~ Cr <br /> (!l <br /> Q <br /> 3 <br /> (Il <br /> w <br /> <:I <br /> C' <br /> ity <br /> r� <br /> c' <br /> Q <br /> m <br /> LL) c <br /> -A (DC3 <br /> to <br /> a <br /> co rs <br /> C11 <br /> m o <br /> N cr <br /> C i rsi <br /> m <br /> L0 CI <br /> CA � <br /> CD Ci <br /> a> <br /> E <br /> Ln Cl <br /> CV <br /> Uya <br /> END 42-04 a <br /> LD <br /> 1014107 SE'r TAGE CLEANERS REiaoRT <br /> 0 ■ ■ ■ 0 <br />