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SAN JOAQUIN COUNTY <br /> EPNIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> < 1868 East Hazelton Avenue, Stockton, CA 95205.6232 72"'of each month <br /> salt; <br /> .: <br /> �. _ Tefephofle:Mill)468.3420 Fex:(209)4644138 Web:W W W.sjgov.Org/ehd <br /> Company Name: G I' _ r SEPTAGE CLEANER'S REPORT <br /> n G c e,Q�C SPV Vif p� Report for the month of Yg,Y year a <br /> Company Address: r.n. Vy-u 'Ajq V tMopA 95 <br /> IRNAtlNNp pn, za aaa Signature: Wl�l onnon <br /> All information submitted .at be eom lata accurate and le ible <br /> MATE NAME OF BUSINESS OR ADDREEa WHERE WORK WAS DONE GALLONS (IQ RESYEIRYL <br /> PUMPED PRDPERTYOWNER NAME OF TFtEATMENT <br /> PLEASE INCLUDE STREET a. DIRECTION. eT0.EET NAPE AHO CITY PUMPED t� 01✓F�TIIAP FACILITY <br /> T2- ea r G EYNRL <br /> 1 I 2 - 0 <br /> Fro e D, <br /> I A Ili N nAe-ML Rd Acarn <br /> 0 22 I coo Rj <br /> e Rc� <br /> I 122 U 8 I1ai D i 50 RL <br /> I 122 UY Ti 22 <br /> 17 r II Vic V 1 0 <br /> 1019 rid 12%0 N PdAre, Vol s h 1000 <br /> IC121 S g4 b4 N Cohn 1500 G <br /> 120 Z 1500 <br /> z hi 1loDD Lodi Zoo <br /> EHD 4204 <br /> INGOT <br /> SEPTAGE GLEANERS;REPORT <br />