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JUL 2T' SAN JOAQUIN COUNTY <br /> m IlkENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> s -jMRONMENTALHEAL-TH 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> �" 'i2"' of each month <br /> � o�:�.- c� p"ITISER OEST;Wephone: (209) 468-3420 Fax: (209)464-0138 Web:www,Sjg0v.or9lehd <br /> LL <br /> SEPTAOE CLEANED°$ REPORT <br /> Company Name: � pr�a vP <br /> /� /3 C Report for the rq0th of: 4:7 -c year d/ <br /> Company Address: ?O/ /C VSCoY /dol 4, <br /> Site-rt .vim v ��. '�3S", Signature: � <br /> Address City Zfp Code G <br /> All information submitted must be complete, accurate, and legible <br /> DA-rE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLOPdS (R) RESNEMTAL <br /> PUMPED PROPERTY OWNER NAME OF TREATMENT' <br /> PLEASE INCLUDE STREET rt, DIRECTION, STREET NA111E AND CITY PUM (G) GREASE TRAP PED {C) GREA7ICAL FACILITY <br /> H -1 Lam., ��b ��✓ Ch L a s�o y - <br /> W Ylot <br /> J Ci / <br /> City <br /> Cit . <br /> <I 4�j�or•1 �'tr C. Uv <br /> <I C / <br /> � f IY�. .+� G <br /> (mr C. �f` �• <br /> Ge re SC4 <br /> - P / <br /> Cil � <br /> rn <br /> 0 <br /> l:il - <br /> 0 <br /> N <br /> � Llt <br /> Cv Cil <br /> u� <br /> cv Cil o <br /> Cd <br /> m <br /> CV � <br /> Ci I <br /> LD <br /> CSD <br /> CV <br /> Page of — <br /> EHD 42-04 — <br /> r– 12J27/13LSD SEPTAGE CLF-MERS REPORT 2 <br />■ ■ ■ ■ ■ <br />