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- <br /> CD SAN JO'AQUIN Co <br /> iJNTY <br /> ENVIRONMENTAL` HEALTH DEPARTMENT Return this form by the <br /> 1868 East Hazelton Avenue, Stockton CA 95205-6232 <br /> Telephone: (209) 468-342-D Fax:(209)464-0138 Web:WWW.Sjgov.org/ehel 12'hof each month <br /> <I <br /> SEPT AGE CLEAP4ER7S REPORT <br /> Company Name: <br /> P0—raJ`Y3 C <br /> / Report for the mo of: I/ yeara0/� <br /> Company Address:_ ;70" oue-e <br /> 5lIQoI <br /> o '�� �4 ���5' Signature: <br /> recl A�Yess Clty / <br /> Zip Cade <br /> All information submitted must lie complete, accurate, and legible <br /> DATE NAME OF BUSINESS OR <br /> PLINIPED PROPERTY OWMER AD DRESS MERE WORK WAS DONE GALLONS (R) RESIDENTIAL <br /> PLEASE J <br /> (G) GREASE TRAP NAI`44 OT 7RPATP�(ENT <br /> H �Q I [JtJC,LyUDE STREET M. DIREC710N, STREET NA7AE AND CITY PUMPED <br /> D (C) cFIErArcA.L <br /> ��c cq <br /> � Gfl OI y Jvo <br /> Li <br /> b-a o r 3y9 <br /> 4 c. <br /> _ Cil Q �j �1fG / <br /> <I 9 sfL4, 16 o <br /> 6 P1.�1►y ra. /�t 6(� _ 62, vrS/-C/e- Cil L ti y Y 3Y/S mGfC <br /> / / y• cel s/��f�' 3 �7 � /i <br /> q CiN C-4 <br /> Aver C% q n <br /> 1� ~ � C� <br /> city 7VO 7L // o <br /> v ` <br /> v OO �— / o <br /> C\4w Ci LC I <br /> `` -t T Gl// <br /> L0 <br /> .. <br /> m <br /> N Cif <br /> s Cil o <br /> <r <br /> N <br /> In Ci <br /> m � <br /> Cit � <br /> n <br /> L0 <br /> M <br /> CV <br /> m ENVIRONMENTALHEALIFFi. Paye of <br /> EH/27113 PERMMSERVICES <br /> � 12127T13 � <br /> m SEPTAGE CLEANERS REPORT <br />