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fiaxt .s� RECEIVED <br /> m SAN J0;4QUIN COUNTY <br /> m ENVIRONMENTAL HEALTH DEPARTMENT <br /> NOV East Hazelton Avenue,Stockton, CA 952fl5-6232 Return this form by the <br /> .9 �w NOV 0 2 2016 Telephone:(209)468-3420 Fax:(209) 464-0138 Web:www.stgo�.orglehd 'I2'' of each month <br /> n ENVIRONMENTAL HEALTH <br /> PERM' R E / SEPTAGE CLEANEWS REPORT <br /> Company Name: pr�a �lvs Y "' // <br /> /� / C Report for the m th o G year v�h <br /> Company Address: ,?p/ /iCOSCo,r �d &"oy 6- gS3S' Signature: <br /> Street Addre3s City 2 p Code �� r <br /> All information submitted must be com lete, accurate, and Ie ibis <br /> DATE NAME OF BUSIIVESS OR <br /> PUMPED PROPERTY OVVNER ADDRESS WHERE WORK WA5 DONE GALLONS (R) RFSJDEIJTWL <br /> PLEASE INCLUDE STREET QB DIRECTION, STREET NAME AND CITY (G) GREASE TRAP NAME OFTREAWENT <br /> V <br /> PUMPED FACILITY <br /> Z �• 3 /Q 4� � � (C) CHEMICAL H <br /> City or /�/4�-i—rGJ �a a ,, `* <br /> Ci (y�9y- <br /> ry �g / C ily <br /> '/O /I/9r vIh l6� *�7c�f o �/ - cn c <br /> !4-/� oltr�+ o I ,ciro f6i? }' ' ,►c�o �!� v Cfra c <br /> Q Ci ✓moi C. awe <br /> city. +c Ood ,/Z <br /> c+[♦, /�C4 `i 5 Cil J %�� C.^ / G..O C-4 <br /> CI 'Poo <br /> Cil <br /> l� Q <br /> C14 <br /> � Cil <br /> CD <br /> V 0c) <br /> cv Ci <br /> to <br /> G-1 <br /> CD C� <br /> Co <br /> V <br /> cr <br /> Cil - <br /> c� <br /> N <br /> OJ z <br /> m <br /> Ci 1 <br /> LD <br /> r-I Gil <br /> CZ) <br /> C\4 _ <br /> N Page of <br /> CD EHD 42-P4 <br /> 12127/13 <br /> .—I SEPTAGE CLEANERS REPORT a� <br /> 0 SON■ ■ <br />