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SAN JOAQUIN COUNTY <br /> ENIVIRONMENITAL HEALTH DEPARTMENT Return this farm by the <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-0232 12f' of each month <br /> Telephone:(209)46B-3420 Fax:(209)4614-013B Web:%wm.sjgov,arg/ehd <br /> f �/ SEPTAGE CLEANER'S REPORT <br /> Company Name: i Q Ccs S �L6 j { Ut� Report for th m th f ye u� <br /> Company Address: /Vn Sfgnatur <br /> Street Add s City Zip Code <br /> All ["formation submitted must be complete, accurate and legible <br /> DATE NAME OF BUSIRESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIOFIMwL HAVE OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED (G� GREASETRAF FAGtLITY <br /> PLEASE INCLUDE ST -ET A, DIRECTION, STREET NAME AND CITY G CRWICAL <br /> rILI <br /> �� <br /> l ot, t' 201__ /�'� l i <br /> C t%l � Z , 0 l' C.-t- Cfly L4 ( Lt <br /> L city <br /> 2( 0 r� dL`�o� �LC� cit, <br /> v � t a <br /> �/vLn cry <br /> A1Z�4. C�' <br /> 6 6 t ( << <br /> CRY k tf <br /> f - <br /> city t 1 O LL <br /> city <br /> Page of <br /> EKD 42-04 SEPTAGE CLEANERS REPDRT <br /> 12127173 <br />