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m SAN JOAQUIN COUNTY <br /> m ENVIRONMENTAL HEALTt-I DEPARTMENT Return this form by the <br /> 1868 East Hazelton Avenue, Stot.ldon, CA 95205-6232 <br /> ,..�.A ' Telephone;(209) 468-3420 Fax:(209)464-0138 Web:www,sjgov,org/ehd q2" °f each month <br /> D <br /> SEPT AGE CLEANER-. 5 REPORT <br /> Company Name: p,.�� J/YS c �.} <br /> / Report for them th of: year <br /> Company Address: _ -'?al �o ee-c 0e,01 � ' <br /> -A. ���s' Signature: <br /> Cl <br /> street Add Escity <br /> Zip Code <br /> All information Submitted must be com lets accurate and le ible <br /> DATE NAME OF BUS114ESS OR <br /> PUMPED PROPERTY OWNER ADDRESS WHERE WORK WAS DONE GALLON'S tR) RESIDENTIAL <br /> PLEASE INCLUDE STREET H. DIRECTION, STREE7 NAi1E AND CITY (G) GREASE TRAP NAME OF TREATMENT <br /> PUMPED FACILITY <br /> H taa3 C4' / �� (C} CHEWCAL <br /> co city �,& 3 9� o< <br /> ` � <br /> CRY <br /> joo �`fr' 4 t C <br /> w 3�-sr <br /> city <br /> 00N, jar <br /> y - <br /> Q tG b9 r�� /iC <br /> s Cduy <br /> OG C d 7 <br /> Ci m <br /> 0 <br /> C o <br /> z <br /> Cil <br /> N o <br /> (14 C Il "-) <br /> CD <br /> V <br /> Nci <br /> Lr) J t <br /> .� <br /> M Ci E o <br /> c PERMIT/SE H TN <br /> a, <br /> C'4 cay <br /> Ci LID <br /> 04 <br /> F-- <br /> m <br /> N a <br /> Page of <br /> .-� EHD 42-04 <br /> 12127/f3 <br /> CD <br /> U <br /> m SEPTAGE CLEANERS REPORT <br /> ■ ■ ■ ■ ■ <br />