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J <br /> m �aLRRI{(rr SAN JOAQUIN COUNTY <br /> AL <br /> m ? ENVIRONMENTAL HEALTH DEPART€b1ENT Return this form by the <br /> 1868 Easf Hazelton Avenue, Stockton, CA 95205-6232 <br /> ct n�J`p <br /> LU <br /> Telephone:(2 09) 468-3420 Fax. (209)464-0138 Web:vrvrvr.sjgov,orglehd 12 of each month <br /> a <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: /� Ora ��YS <br /> s � Report for the mo of: r7'{ <br /> Company Address: ?O!1 <br /> ntG3Co-e IQd �a(lamss ,® � CA ?'33 Signature: <br /> Zip coaz (cue r• <br /> All information submitted must be Com fete, accurate, and to ibe <br /> DA7E NAME OF BUSIIVESS OR <br /> PUMPED PROPERTY OWNER ADDRESS WHERE WORK WAS DaRIE GALLONS fR) RESIDEtITfAL <br /> PLEASE INCLUDE STREET 0, DIRECTION, STREET NAME AND CITY PUMPED (G) GREASE TRAP <br /> A1AN9EOFTREA7A9ENT <br /> Z n. (Of CHEMfCa� FACILITY <br /> ,�11 3 2q . <br /> w IarT�irc t-•us dj �// 7y 't C-t <br /> Fa L� w �~ "" CH x G aG�J f/ <br /> 0 6_�3 L <br /> -y— 5-r <br /> n00 <br /> �a <br /> g C <br /> 'K - <� <br /> �l►C� p�G Gil [�J 1, C�D <br /> Cq <br /> AL <br /> w4Cyl/Ca1 Oi L f <br /> 4 <br /> V /Y`IO /►CCti CII <br /> r— <br /> 1 <br /> N dCGI� <br /> /1.! ®I L S Ci O� o <br /> .40 Go <br /> Ci <br /> cn <br /> m ? <br /> c. <br /> co <br /> q Cit <br /> CD <br /> C\l g <br /> JUL 1 1 2018 Page of <br /> EH D 42 OQ <br /> 1 V27M ENVIRONMENTAL HEALTH <br /> m <br /> PERMIT/SERVICES SEPTAGE GLEAiYERS REPORT <br /> ' - <br /> ■ mm ■m51 <br />