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RECEIVED <br /> paeld. SAN JOAQUIN COUNTY <br /> JAN 0 3 2019 ENVIRONMENTAL HEALTH DEPARTMReturn this form by the <br /> ENT <br /> ENVIRONMENTAL HEALTH 1868 East Hazelton Avenue, Stockton, CA 95205-6232 92u of each month <br /> `�- DEPARTMENT Telephone:(209)468-3420 Fax:(209)464-0138 Web:wvrw.sjgov.orglehd <br /> SE=PTAGE CLEANER'S REPORT <br /> Company Name: Q �{ S tG vt` Reportfor hem th of• yea'v"- <br /> Company Address: S� Signatur <br /> Sty! cffy Zip Code <br /> All information submitted roust be complete, accurate, and legible <br /> GALLONS {R} RFsmEriz{AL A1AT�4E OF TREATMENT <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE {G} cR>✓asErRAr FF CIi i7Y <br /> PUMPED PROPERTY OWNER PUMPED <br /> PLEA6E INCLUDE STREET P, DIRECTION, STREET NAF�E ANO CITY C} CkEillCAL <br /> S S <br /> b�Y-b to i{ <br /> Io <br /> c: r <br /> a_ c Z MIA t---t o <br /> c <br /> m <br /> tc <br /> I <br /> city <br /> 0 <br /> city <br /> m <br /> C <br /> I <br /> City <br /> CRY <br /> Page of _ <br /> ti <br /> SEPTAGE CLEANERS REPORT <br /> EHD 42-04 a <br /> 12J27113 <br /> ■■■ 0■■■ <br /> ■ ■ ■ ■ <br />