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m �aulry E® <br /> SAN JOAQUIN COUNTY <br /> r ENVIRONMENTAL HEALTH DEPARTMENT MAY 0 9 <br /> m Z�� Return this form by the <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 12d' of each month <br /> .�a i.a��k .. TOIephone: (209)468-3420 Fax:(209) 464-013B Web:www,sjgDv.or"ERMIT/SERVICESRCNMEIV7)gLH <br /> Il <br /> SEPTAGE CLEANER.'S REPORT <br /> Company Name: <br /> / c Report for the th f: yearo�0/ <br /> Company Address: ?Ore C., Signature: <br /> Street Address City Zip Code y <br /> All information submitted must be complete. accurate, and fe ible <br /> DATE NAME OF BUSINESS OR {R} RMDENTIAL <br /> PUMPED PROPERTYOWNER ADDRE5SINHI=RE1140RKWASDONE GALLONS NAM E OF TREATMENT <br /> U <br /> PLEASE INCLUDE STREET d, DIRECTION, STREET NAME AND CITY PUMPED (G) GREASETRAP FACILITY <br /> Z �� /1 {Cl CHEMICAL <br /> H arg+r ... IS600 <br /> Ul C irly re 99v <br /> r Cil f'�r� <br /> 100, <br /> a <br /> ~ Ciry <br /> 0IL <br /> oc CCIO <br /> e, rY� v. ,c Scity <br /> Q _ y <br /> 452 AY CM <br /> city <br /> Cil <br /> r_ <br /> L'I o <br /> Cil o <br /> z <br /> Ci a <br /> N � <br /> CA cr <br /> - <br /> m cr <br /> V <br /> � Ci <br /> m <br /> m 'o <br /> CV <br /> CL <br /> LD <br /> CA city <br /> MSECD <br /> Ci <br /> CD Cil <br /> 04 <br /> m Page of <br /> CD EHD 4204 — <br /> tp 37/27/73 a, <br /> CSD SEPTAGE CLEANERS REPORT a <br /> ,y <br />■ ■ ■ ■%■ <br />