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CED <br /> CS) 1O SAN JOAQUIN COUNTY <br /> A' :< ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> w1868 East Hazelton Avenue, Stockton, CA 95205-6232 12'' of each month <br /> `q • Telephone: (209)468-3420 Fax:(209) 464-0138 Web.'www.sjgov-orglehd <br /> SEPTAGE CLEANEWS REPORT <br /> Company fVarrle: e <br /> 3 Report for the mo of: OQ, �/7 <br /> //�� !� / yy� year <br /> I;ompanyA dress: _ �?O/ /LOSC,*-t 1�a� &. <br /> Slreel Address CiLy Signature: �. <br /> Zip Code <br /> All information submitted must be cum tete, accurate, and legible <br /> DATE NAME OF BUSINESS OR <br /> PUMPED PROPERTY OWNER ADDRESS WHERE UUORK WAS DONE GALLONS {R) RESIDENTIAL NAME OF TREATMENT <br /> � PUMPED (G) GREASE TRAP <br /> Z PLEASE INCL STREET N, DIRECTION, STREET NAME AND CITY FACUTY <br /> H {C) CHENdCAL <br /> IXI <br /> F_ r CI �, <br /> IE 9 C��•� }, �. Cil '� 3 S 2 ., <br /> i ,- c 9 �� Y l' A vr,&7 �•w I°L ciI rYst ?e-. Ira v i •y <br /> 'f oYo ul.. L - <br /> �/ 9� K �{ ca a'cf +-s 1a�s40 <br /> 9 C'7 �i►A /4 Y• ��t 7 C /nCiE /r�l1�c �, eZ�da <br /> LLQ �i' Ci16 <br /> S ca slog, 1L y <br /> .3a � _ <br /> dvp� �IY�r �j •� �/ <br /> N CiL C w <br /> V N <br /> C14 C <br /> LD <br /> Ale <br /> N <br /> �2 ♦ar ��.s I o <br /> Cif ` � s• � �{ I <br /> � /�q� 17 A' V♦�`a s Gil �� V Al <br /> CV / <br /> m <br /> CV C rt <br /> a� <br /> CED <br /> G0W. <br /> Page of > <br /> L0EHD 42-04 <br /> RE \1 <br /> M 17127113 SEPTAGE CLEANERS AEPQRT � <br /> 0 <br /> ■�0 E JUS N <br />