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�r <br /> CL SAN JOAQUIN COUNTY <br /> 3 ENVIRONMENTAL HEALTH DEPARTMENT Return this form by,the <br /> 600 East Main Street, Stockton, CA 95202-3D29 12th 01 each month <br /> Telephone:(209)468-3420 Fax:(209)404-0138 Web. www.sjgou_orWehd <br /> SEPTAGE CLEANER'S REPORTCompany Name; 64s-, -RLfi�vr �,� C f � C�.0 Report for the month of: �'� year 7-o i O <br /> Company Address: �,L�,1 5-rk74 gso5 Signature: <br /> Street AdI es s City rip Code <br /> All Intoern tion submitted must be complete, accurate and Ie Ible <br /> e DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS CONE GALLONS (R) aestnon� NAME OF TREATMENT <br /> PROPERTY OWNER PUMPED (1) GREASE MAP NAME <br /> PLEASE ANCLUae STREET r, DIRECTION, STREET MARIE AND CITY C CHEWCAL <br /> , 5iz&— Fylyaw am mom— a 114 l 51D <br /> no .r d -IS,Tk-N 11500 <br /> ok <br /> Nr off' 3�iS r'� a.�^Ga c �'I�L ? 1� <br /> 0r Sia 'f' c )C-F1t' <br /> aV2nes e 15"va <br /> N C' S <br /> P 5el— Aj 1 <br /> C, Cdy <br /> {7 �i4�r <br /> ry coy <br /> City t <br /> city <br /> city <br /> t <br /> I � <br /> a <br /> C- <br /> N <br /> CRY <br /> rY <br /> CD <br /> O C <br /> C7 <br /> N M <br /> a: EHD 4Z" <br /> rl 7014107 SEPTAGE CLEANERS REPORT <br /> z <br />