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N 0 <br /> 0i�� <br /> _ al 4 SAN JOAQUIN COUNTY Return this fgrm by the 07 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 12n'of each mouth O <br /> Telephone:(209)468-342(3 Fax:(209)464-0138 Web:www.sjgov_orglehd m <br /> . <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: Cc- ��-CGC Report for the th of: year z22 �n <br /> T7Ake, Signature:1�3 <br /> Company Address: <br /> creel CIh ZIP Code -Tl <br /> 70 <br /> All information submitted must be complete. accurate, and legible <br /> ti DATE NAME OF BUSINESS OR AD DRESS WHERE WORK WAS DONE (R) PEserarrvu 3 <br /> GALLONS NAME OF TREATMENT <br /> o PUMPED (G) GREASE TRAP FACILITY D <br /> PUMPED PROPERTY OWNERPLEASE INCLUDE STREET 0, DIRECTION, STREET NAUE AND CITY C CHEIUCAL <br /> W H <br /> o � <br /> W <br /> O - H <br /> W <br /> 1 0 <br /> 0 <br /> I LUIS o <br /> ENVrt IC <br /> NiEnJT i <br /> Oty <br /> cn <br /> Cily <br /> clty <br /> COY <br /> I <br /> m <br /> i <br /> 3, 7/ Czy <br /> N <br /> Uym <br /> m <br /> m <br /> r-' <br /> W <br /> N <br /> Cey <br /> city <br /> city <br /> E7 D 42-04SEPTAGE CLEANERS REPORT <br /> r-' <br /> ti3f�'07 <br />