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SAN JOAQUIN COUNTY <br /> m _t ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Ret of each month <br /> ILL! e ,, �., Telephone,(209)468-3426 Fax: (209)464-0138 Web:www_sjgov,orglehd <br /> n <br /> SEP'TAGE CLEANER T$ REPORT <br /> Company Name: <br /> / �ry� Report for the mo tit of C} yearG?a/�j' <br /> Company Address: �O! �o3eo-r Rot _ ys <br /> Street Address 3S� Signature: <br /> CaTy Zip Code <br /> All informafion submitted must be cam left, accurate and legime <br /> DATE N:AR4E OF BUSINESS OR <br /> PUMPED PROPERTY OMER ADDRESS WHERE WORN WAS DONE GALLONS (R) RESIDEt¢]1AL <br /> PLEASE INCLVDE STREET A, DIRECTIorf, STREET NAME A}lo CJTY lr'? GREASE TRAP NAME OFTRE:ATROENT <br /> PUMPED FACILITY <br /> <401 �� �s6 ro ��� �2 Az. <br /> rn �/z uu. cIL ✓Y c. p ��g c. <br /> J c a U /,r <br /> ry <br /> n P4 "-two 11,ZQ <br /> <I t — Ci <br /> 00 <br /> V- U - C:iI - <br /> cr� Yc`Y <br /> ti a ti f r ci <br /> r <br /> ca rl`7 r <br /> _3 95 Lgy� <br /> cit <br /> 3Y95� <br /> cil �-< < d, <br /> r r r9 cl <br /> C , <br /> Ci 95Lo <br /> Cn <br /> 04 <br /> �� I <br /> ,✓ <br /> LAG/, - ���, a. � S �f Lo <br /> CIL DU C- � <br /> Lo <br /> 17 4 arsee"t <br /> W <br /> CiL <br /> CD Cit <br /> CV <br /> Page of <br /> EHD d2-D4 <br /> C14 <br /> U <br /> m 5EPTAGECLEANERSREPORT <br />