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`:. SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> =_ 600 East Main Street, Stockton,.CA 95202-3029 92 'of each month <br /> a Telephone:(209)466-3420 Fax:(209)464-013a Web:www.Sjgov_org/ehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: l 0-to Roofer jt- - � <br /> Company Address: + � <br /> -#ZZr3 � _ Report for the th of: year 2-0J <br /> ' .� 14 �f Ci's 2,0 Signature: . Y <br /> Street Address City 75P Code <br /> All Information submitted must be tornlate, accurate and legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS IR) mesimNnAL NAl11E OF TREATMENT <br /> PUMPED ; PROPERTY OWNER PUMPED IGJ GREASETaAP FAGILEA <br /> PLEASE INCLUDE STREET S. IDISECTION, STREET NAME AMID CITY C CNEWCAL <br /> FY <br /> 3:.* ' ti et" fr.hl 2iS�r Wrz r^ C* SrtK 33$ti <br /> ST K N 44E <br /> 3 : J �fafml �-J ets' - f32-10 G , - r city ;f 4C N, � Rd �� <br /> firs o llC 5G-�# ' r5 x s1G s4' c. {'� N r1�0-r0 <br /> '144 city N 801D <br /> c n Qk n J r r h+ W5ie'.e' !mak ow ST'K N (2,00 s '-� <br /> 1 r- c. `' CKti �I R <br /> _n4- U" r nd <br /> city S-1 1�1' 3. 2 <br /> Acio-ais r.fi. city G-� k N ,f-�- <br /> m rr, <br /> 3'I� ` c�CK.toC3 11 <br /> CILY 'S " <br /> v V T1 J L �. k r <br /> co <br /> Cc - �':,-- r c Sj-rKN 33$2c3 <br /> DuVrfria5 � 1o53i f- �iI' +h. <br /> c� �—K 1 f4. <br /> i ; 1 <br /> .�I <br /> nut <br /> fr. 0' L40 City <br /> b r 2-Scg �-',a 'C.h lrn 1 KN <br /> Tf�i r r(1� 5 '� 17t't r ' �-) 1570 Q <br /> _ I c r <br /> Fr,L r)K 60 l,, A1A watA' •2- c. , Y <br /> r <br /> C h 2_0 Sha to Rd Cfty J'r K N 3 81 <br /> Ln <br /> wa i <br /> a Y S f`r -S KN 3337cm <br /> cm <br /> EHO 42-04 <br /> y 1014107 SEPTAGE CLEANERS REPORT <br /> a <br /> b <br /> 0 <br /> ry <br />