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SD SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue; Stockton, CA 95205-6232 Return this form by the <br /> 12ff' of each month <br /> "<� .� Telephone: (209) 468-3420 Fax:.(209)4640138 Web:MWI.sigov.orglehd <br /> <_L <br /> SEP SAGE CL,EANEf4'8 REPORT <br /> Company Narne: � Or�ei J` lvS g c <br /> Company Address: <br /> / Reportfor them th of: �� year p?D/ <br /> a0/ 20 Co,r �d � �5. 3 <br /> Signature: <br /> Czy <br /> Zip Code <br /> All information submitted must 6e complete, accurate, artd le i61e <br /> DATE NAME OF BUSIIJESS OR <br /> PUMPED PROPERTY OWNER ADDRESS WHERE WORK N1AS DONE GALLONS (R) RESWENTtAL <br /> PLEASE rNCLUDE STREET 4, DIRECTIDN STREET NA6tE AND CITY (GJ GREASE7RAP NAft9EOF'fREATMENT <br /> y PUMPED FACILITY <br /> SCJ CHF KCAL <br /> H ao oa or o ( 'C Cit !Jeff l <br /> co <br /> S <br /> Ld <br /> - <br /> O <br /> n <br /> Cii <br /> 2a� ,, , <br /> t, <br /> Ci 3 95 /z 1i <br /> City /c. r d <br /> 747 <br /> LO <br /> Cit <br /> N CN o <br /> V <br /> C� L� <br /> V <br /> N CI I <br /> CD _ <br /> C� Ci o <br /> N cv <br /> C'4. <br /> Ca cily bn <br /> CD Q <br /> CD <br /> Ci I <br /> CD C jt <br /> m <br /> N <br /> Page o{ a <br /> .—I EHD 42-D4 <br /> 12127!13 <br /> m SEPTAGE CLEANERS REPORT a <br />