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RECEIVED <br /> OVA <br /> SAN JOAQUIN COUNTY <br /> APR 0 5 2017 ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 1868 East 1-[azeiton Avenue, Stockton, CA 95205.6232 12th of each month <br /> �WALHM*1ephone:(209)465-3420 Fax: (209)464-0138 Web:m%w.sjgov.orglehd <br /> PEIl111lT/$ER'VMM <br /> S TACE CLEANER'S REPORT nn <br /> Company Name: Report for th, bh of, ye R_ <br /> Company Address: ` VP Signatu 111 <br /> Street AiJdress City tip Code q <br /> All information submitted must be complete, accurate, and legible <br /> DATE NAME OF BUS114ESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENA3IAL NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED (Gk GREASETRAP FACILITY <br /> PLEASE INCLUDE STRE T V. DIP.ECTION, STREET NAME AND CITY (C) CHEMICAL <br /> city Q <br /> 1. l;; q Lk <br /> t � T i ! �} -�, -city � fl moi... <br /> -33 (1 T <br /> 3 ` l 'D dr.4 <br /> Gay <br /> - e Q <br /> r <br /> c__ ityC L o <br /> cityL[ { rl <br /> 0 <br /> city <br /> C. , ori <br /> city <br /> Q <br /> cc <br /> t <br /> cry <br /> Page of <br /> EHD 42.04 SEPTAGE CLEANERS REPORT � <br /> 1=7113 <br />