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aG`141Iry RETE, <br /> CSD 'e�;.c� SAN JOAQUIN COUNTY MAY <br /> V <br /> CD 3 ENVIRONMENTAL HEALTH DEPARTMENT ►°��1/ <br /> 1868 East Hazelton Avenue, Stockton, CA 952D5-6232 V Z0i8 Return this form by the <br /> — <br /> H <br /> ."a«, 0 Telephone:(209)468-3420 Fax:(209)464- 138 Web:www.sjgov.org/" IYMLcVT 12 ' of each month <br /> tU <br /> � RMITiS�R��S CTH <br /> // <br /> SEPTATE CLEAMER'6 REPORT <br /> Company Name: p r�a �fY3 C Report for the mo <br /> / h f; r l year4pq�?r <br /> Company Address: i?Ol2o3Ca,r 14G� ® o �S ��3s7 <br /> Street AddrSignature: <br /> Address City 9 <br /> ri Zip Code A.— <br /> Ali Information submitted must be Com lete, accurate and le /0,- <br /> ible <br /> DATE NAM OF BUSINESS OR <br /> PUMPED PROPERTY OWNER ADDRESS VIIF{ERE WORK WA,-DflPIE GALLONS (R) RESIDEHIIAL <br /> PLEASE IroCLUDE STREET d, DIRECTION, STREET t1Al.1E AtQO CITY (G) GREASE MAP NAME OFTRIATMENT <br /> PUMPED FACILITY <br /> o1e <br /> lolq5 <br /> �� �C} CC//H�EA7ICAL ��/��/ <br /> Z / !_` <br /> L <br /> �. <br /> 0 �d / <br /> n <br /> _/ ct l� el <br /> Q �� <br /> Q S�� .040 �'r`C �t✓� ci bowtv <br /> Gil <br /> I ti-c 6F.7 7 <br /> N�► Gil ~'p t• �/ � <br /> +''fit eY1% <br /> el V11 01 <br /> v ` �J <br /> 37v 114 ee-- <br /> m <br /> /�• �� Ci1 J� Q� /i <br /> L0 l <br /> (V c-4 <br /> t <br /> Ci <br /> (Yl <br /> m � <br /> Cil l <br /> CO <br /> � Ct <br /> CD <br /> cv . <br /> Page of <br /> -i F--HID 42474 <br /> 12!27173 <br /> L0 <br /> CD 5EPTAGECLEANERs REPORT <br /> .�'M% <br />