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`� aa4xin,. <br /> SAN J AQUiN COUNTY <br /> m ` EWRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 1868 East Hazeiton Avenue, Stockton, CA 95205-6232 <br /> 12u' of each month <br /> LU "%�•,a;, � Telephone:(209) 468-3424 Fax: (209)464-0138 Web:VAM-Sjgov.orL3lehd <br /> <I <br /> SEPTAGE CLEANEB'$ REPORT <br /> Company Name; pr v-5 <br /> / c Report for the <br /> nth <br /> of: <br /> v yearp�o/� <br /> Company Address: ;?6712osta,r /Qd J0111 �4 <br /> Stue-t Address Cary Zip Code 3S' .Signature: r <br /> All information submitted must be complete, accurate, and le ible <br /> DATE (NAME OF BUSINESS OR <br /> PUMPED PROPERTY ONfNER ADDRESS WHERE WORK WAS DOME GALLONS (R) RE-ME01AL <br /> IG) GREASE TRAP NAME OF TREATMENT <br /> PLEASE INCLUDE S7REET A, DIRECTION, STREET N ME AND Cr7Y PUMPED FACILITY <br /> U t <br /> H �6Sir, <br /> 0�15C CJ CNEldICALCJ4r G C t ✓c.4 6 7 LLI <br /> (/ / <br /> o j ti `� 6 0 1� �/- y� Ci Jr \ / fq WC q <br /> n !/ / C4�� Y r ti Dao p_,p^ dC( r.w K /7 r� d'SrG� <br /> a <br /> SZ-- /, C , <br /> Ci <br /> City <br /> Cir <br /> Ci o <br /> z <br /> C(1 a <br /> t� <br /> V Gil <br /> CS) �t <br /> C'4 <br /> L0 <br /> m <br /> NCi oC-14 <br /> ctl o . <br /> L0 City <br /> L0 — <br /> (!D Gil <br /> 04 a <br /> CD Page <br /> END 42-D4 -— <br /> CT) 12><7!13 <br /> m SEPTAGE CLEANERS REPORT a <br />