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m b4ulry. RECEI <br /> �SANJOAQUIN COUNTY MMM <br /> ? ? ENVIRONMENTAL HEAL7H DEPARTMENT <br /> Return this form by the <br /> 1868 East Hazelton Avenue, Stoddon, CA 95205-6232 FEB 0 9 2015 12th of each month <br /> '<ibt� c•. Telephone:(209) 468-3420 Fax: (209) 464-0138 Web:wvwv.sjgov.or /ehd <br /> IL ENVIRONMENTAL H ,i <br /> SEPTAGE CLEANER't . <br /> S REPORT PERMIT/SERVICES LT <br /> Company Narne: <br /> —4A� O r�� 'J�JS <br /> Report for the th o : year O/S <br /> Company Address: - i?O/ 20 ce,r /Q� �c �S ��35' Signature: ` <br /> Sheet Address y - <br /> Cfl Zip Cade � <br /> All information submitted must be CDm lete, accurate, and re ibre <br /> DATE NAME OF 6USiNESS OR <br /> PUMPED PRO <br /> AD DRESS WHERE WORK WAS DONE GALLONS tR) RES[DENML NAME OF TREATA9ENT <br /> PLEASE INCLUDE sTREE7 1q, DIRECTION, STREET NAME AND C17Y PUMPED (C) GREASETRAP FACILITY <br /> V // t/4 ( ) CHaIICAL <br /> T7 <br /> �2 Q.,, oc 4 �� cit ` q <br /> 3Yys <br /> W <br /> o cit y <br /> �_� ✓y4z IK 600 w Crap dL`4�J city Yom.. C 71. 7 2 <br /> 0- �+ G <br /> CIO <br /> Its, <br /> ca <br /> cit <br /> 0 <br /> r_ <br /> CiI a <br /> Cit � <br /> z <br /> Cit <br /> rn <br /> CV m <br /> - <br /> M m <br /> V <br /> cv Cil 9 <br /> L0 <br /> on <br /> mCiL oC-4 <br /> s Ci o: <br /> n <br /> N <br /> m city <br /> co <br /> m <br /> ca <br /> L0 — <br /> r-+ Cit I— <br /> m <br /> 04 o <br /> Page 7of <br /> CD EHD42-04 - <br /> N 12!27113 <br /> CD SEPTAGE CLEANERS REPORT a <br /> �y <br />■1 ■ ■ <br />