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as <br /> ¢., �-.,,q :.:� SAN,IOACiUIN COUNTY <br /> ENVIRONMr:NTAL HEALTH DEPARTMENT Return this form by the <br /> 600 East Main Street, Stockton, CA 95202-3029 12e of each month <br /> K Q:' Telephone. (2 09)468-3420 Fa c:(209)464-013B Web:www.sjgov_orglehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: U R Y T)L'it t- - Report for the month of: year 2 o i 4 <br /> Company Address: '+Z29 AJC+,,,n el 4 �� ! 5 2�0 C:� Signature: <br /> Strad Address City Tip Code v <br /> All Information submitted mUSI be Complete. accurate, and is Lble <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) MANE OF TRE.ATIII ENT <br /> PUMPED PROPERTY OWNER I PUMPED (GI sREASE TRAP FACILrrY <br /> PLEASE INCLUDE s7REET s, CIRECTION. STREET NAME AMC CITY (ClCKEMICAL <br /> 01y i?-00 <br /> lar) co Rej CI, 67&q . TZ <br /> N <br /> O <br /> CO <br /> Ln C. <br /> N <br /> city <br /> CRY <br /> i <br /> i <br /> } <br /> F14CAY <br /> I i <br /> [� <br /> Q' <br /> CM C- <br /> rl <br /> rq <br /> N <br /> EHD4244 \ <br /> Son 4" SEPTACE CLEANERS REPORT <br /> i Z�J S .� <br />