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m hsulrl,.� SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> CD ' K <br /> Return this form by the <br /> 1863 East Hazelton Avenue, Stockton, CA 95205-5232 12�' of each month <br /> ' � 6,��,' Telephone: (209)468-3420 Fax: (200)464-0138 Web.wwW.Sjg1DV.org/ehd <br /> <I <br /> SEPTAGE CLEANER'$ REPORT <br /> Company Marne: Or/ z �1,eS 4 c - <br /> Report for h of.- year <br /> Company Address: / 493car 14 / <br /> o .tea n CIS. ,S3s' Signature: 0 .. <br /> Sleet Address City Zip Cafe <br /> All informatiDn submitted mast be Complete, accurate and legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RFst°sRrlai NAME OF TREATMENT <br /> PUMPED PROPERTY OWMER PUMPED (G� GREASE TRAP FAClL1TY <br /> / PLEASE INCLUDE STREET N, DIRECTIOtI, STREET/NAME AAtdD CITY yp (G C}iE69CAL _ <br /> H FQ / AV D Cil L cw H-o <br /> w - 3 �, I/ <br /> I cll <br /> 3 Ar <br /> ry <br /> City <br /> 4 c% 3 j+4q <br /> <I <br /> aI j.4 . �`rY •i ,(�C Cil <br /> GC -l+C4 a <br /> cit <br /> cii <br /> 0 <br /> city <br /> 0 <br /> CIL � <br /> a <br /> v <br /> m d- <br /> V <br /> (V <br /> city <br /> Lc) aLs� <br /> O'1 <br /> COVNib <br /> Cil o! <br /> U LID <br /> o� <br /> ciry IR©NME AL HEALTH <br /> E <br /> PRM1 r - ' o <br /> Ci <br /> a <br /> + cit <br /> m <br /> Page oto a <br /> m <br /> EHD 42-04 a <br /> CV 12127113 SEPTAGE CLEANERS REPORT <br /> a, <br />