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cow „ SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form b <br /> { RECEIVE y <br /> 600 East Main Street, Stockton,CA 95202-2708 the 12`h of each month <br /> Teleplron (209)468=3420 Fax:(209)464-0138 Web:www.sjgov.6rg/ehd {� { r <br /> c4`�FpR`'`P # ` AUV 0 8 291 <br /> % ti. SE TAG CLEANER'S REPORT <br /> Company Name: <br /> Report f ;Krw p <br /> Company Address: Siture• <br /> gna <br /> Street Address t City Zip Cade <br /> All information submitted must be com tete, ac 'urate, and legible Fri <br /> • z , <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS �R) RESIDENTIAL NAME OF TREATMENT. <br /> PUMPED PROPERTY ONi'NER PUMPED (G) GREASE TRAP FACILITX 3 <br /> J PLEASE INCLUDE STREET k, DIRECTION, STREET NAME AND CITY C) CHEMICAL - <br /> ���..• City <br /> f d Cit ' ad <br /> � Cit <br /> Cit <br /> f '' s' •�4 Z <br /> city <br /> 34 <br /> City <br /> - - Cioff <br /> f <br /> .� <br /> ,} cit <br /> City <br /> ��-ll If� �• .r/ Citvs7l' �.•✓ ZDV �-� <br /> Cit <br /> Ci <br /> Cit <br /> -�r� ;� �/,� �✓ <br /> City � <br /> Ile <br /> cit S SdeQ [� r� <br /> ;t <br /> EHD 42-U4 ` <br /> p c/Ce p Irt <br /> ep <br />