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RECEIVE <br /> SAN JOAQUIN COUNTY <br /> z; ENVIRONMENTAL HEALTH DEPARTMENTJReturn this form by the <br /> AN , <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 5 206 12t' of each month <br /> Telephone:(209) 468-3420 Fax:(209)464-0138 Web:www.sjgo f.")��_ENT H <br /> �`vrvM <br /> SEPTAGE CLEANER'S REPORT AL <br /> PERMIT�SERVIC Sot TH <br /> Company Name: iJ��/L%/� lXJ•, 59d PGL�1�/� (;U_ Report for t nth of: year <br /> — / � / <br /> Company Address: ���3�2'/E`i�Y/2 ,UL. r��cnri~.9�,-I,�v7ZJ� �Q �5�.3� 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 GREASE TRAP FACILITY <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY C CHEMICAL <br /> / -y-is' ,��✓-vu%r�F �/ i ��a yo <br /> City az s <br /> City <br /> �oZ %r/J✓ �S 8S �6 r �;li4�G�i9� le04-0 Cit 11 1 t [ I <br /> cit <br /> Cit <br /> city <br /> cit <br /> /�/ ,f/0 1 ��nl,(�/ t �v�,u��F ����CIv�L.,�l�i(��y Cit <br /> `' 'vU Y& I.� L o !iv(�'� /(..ti/1q✓Jrip�Y Cit <br /> �/ s `�D �TTG' �� G�✓� City A <br /> City P Sd t <br /> Cit <br /> ✓/ fid/�i�tT t/ �/Il/Y% ,//� �/��L �j SCI/y//�//'�iI'� <br /> City <br /> G►� (l i r t <br /> City <br /> Q LIP—. <br /> �� <br /> S `� 1�^��/d ✓� '3t. w� -tl U'� ) it + cit <br /> /DcCit <br /> Page / of . <br /> EHD 42-04 SEPTAGE CLEANERS REPORT <br /> 12/27/13 <br />