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alsoF <br /> $ANJOAQUIFE COUNTY ! <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> ' ' 600 East Main Street, Stockton, CA 95202-3029 12 of each month <br /> •i uN �N�H�E� Telephone:(209)468-3420 Fax:(209)464-0138 Web.www_sjgov.orgtehd <br /> 7 SERV CLEANER'S REPORT <br /> � � PER�II�I SEPTAGE CLEAN � • <br /> Company Name: n vi nn-<C Q c Report for the month of: year 03 <br /> Company Address: __.. i oZit t mit r)&. r`YLoCAw G� _e I "tel C �T��} Signature: <br /> SlreetAddress City ZPCode <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 (0) GREASETRAP FACILITY <br /> PLEASE INCLUDE STREET 9, DIRECTION, STREET NAME AND CITY C CHEMICAL <br /> Aja pUnNo PAi <br /> ritv <br /> 0 CRYm <br /> Lr) City <br /> L <br /> w city <br /> CA <br /> w Ci <br /> C <br /> .+ Cit <br /> E City <br /> 3 <br /> city <br /> M Cit <br /> +) <br /> C <br /> W <br /> city <br /> E <br /> c" <br /> ca <br /> C Cltv <br /> w <br /> cI <br /> CL city <br /> N <br /> rd Cit <br /> City <br /> Q <br /> O <br /> to EH©42.04 SEPTAGE CLEANERS REPORT <br /> 11V4107 <br /> W <br /> A <br />