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�PCLjSAN JOAQUIN COUNTY <br /> � Return this form by the <br /> HEALTH DEPARTMENT <br /> ENVIRONMENTAL <br /> w1868 East Hazelton Avenue , Stockton , CA 95205 - 6232 12t of each month <br /> M moo �' Telephone : ( 209 ) 468 -3420 Fax: (209 ) 464 -0138 Web : www . sjgov . org /ehd <br /> SEPTAGE CLEANERS REPORT <br /> SC -� i c, Q Report for them th of : Pcert 1devear � � <br /> Company Name : �1 <br /> Company Address :o9 UL4 3 Pry KVjoY. F , d Y%* C - Cr 95& & 1' Signature : <br /> Street Address City Zip Code <br /> All information submitted must be complete , accurate and legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAL NAME OF TREATMENT <br /> PUMPED PROPERTY OWNERPUMPED ( G ) GREASE TRAP FACILITY <br /> PLEASE INCLUDE STREET # , DIRECTION , STREET NAME AND CITY C CHEMICAL <br /> o? - fl ( loon �'► 9lo`�C /l1 , f-/�v � 9 Citycc, m v 00 �� 1 <br /> � - Arb © r Mlef P � lR o /U . � � � Cit c�At o & 0 co � Ads <br /> HP � a ) 14 %Awp ? 9 Cit e�q t^7 APO Ciao 1 9 <br /> wild GIr� eSP IQcxffr4 (P6t N < (Uerogec tc) A � Cit L-o o%r' � T <br /> 2 - Po /' /Lt cl 1 6120 /� ` `'/� ! l Cit 09 < 5 <br /> Af %v - Cit C� �d U <br /> TT� <br /> /1001 � �s' 0 I , Cit � � C ) j S V1 i.C .� <br /> - c14 ! 4 0 <br /> 4r 6wi / U 11 v �� w Cit �I�%� eo /& Ca <br /> �p ti A Citwo <br /> y j r bcAs) <br /> citv <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> city <br /> Cit <br /> Cit <br /> Cit <br /> EHD 42 -04 SEPTAGE CLEANERS REPORT <br /> 1014/07 <br />