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RECEIVED <br /> ►°tR �u SAN JOAQUIN COUNTY <br /> APR 0 5 2018 ENVIROIVENTAL HEALTH DEPARTMENT Return this form by the <br /> 186B East Hazelton Avenue, Stockton,CA 95205-6232 12'h of each month <br /> ENVIRONMENTAL HEALTRetephone: (209)468-3420 Fax:(209)464-0138 Web:www.$)gov.orglehd <br /> PERMIT/SERVICES <br /> / SEPTAGE CLEANER'S REPORT <br /> Company Name: 0Report for the h of: <br /> C� <br /> Company Address: ?� 4 ?S3 Signature: <br /> Spee Address Cite Zip Code <br /> All intormatlon Submitted must be complete, accurate and legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONSLR' LRE-M <br /> Eimri NAME OF TREATMIENT <br /> ?U>J1PED PROPERTY OWPlER PUMPED sT� FACILITYPLEASE INCLUQE STREET ?, DIRECTION, STREET NAVE. AND CITY IC,AL <br /> (0 city dkz'140� 6 <br /> 67 <br /> CityL-3 -9 ,Ka� u <br /> Q Ca Lir Z 4f <br /> CZ -3!j <br /> city 3ooc7) <br /> 0 <br /> q Ic city <br /> nJ <br /> "� C L( <br /> Q <br /> f 4 CP o <br /> c <br /> city <br /> �o Y <br /> C� <br /> GU <br /> Page of <br /> EHE)42-4 SEPTAGE CLEANERS REPORT <br /> 12127/93 <br />