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aA�l RECEIVE® <br /> SAN.IOAQUiN COUNTY <br /> JUL Q 2 2018 ENVIRONMENTAL HEALTH ©EPARTt�EN—f <br /> 9868 East Hazelton Aven Lie, Stockton,CA 95205-6232 <br /> EReturn uofthis forth fay the <br /> Telephone.(209)468-3420 Fax:(209)464.0936 Web:www.Sjgov.onj1e€�d of each month <br /> ENVIRONMENTAL HEALTH <br /> PERMIT/SERVICES SEPTAGE CLEANER'S REPORT <br /> Company Name: .• <br /> C <br /> �Q r- S 'St .cG /`L)L` - <br /> Report for tFte o of: year ao <br /> Company Address: L <br /> S[reetAd s S 3 Signature: <br /> Cfty Zip Code <br /> A(l information submittedmust be complete, accurate and le lble <br /> DATi= NAME OF BtlSf IIESS OR <br /> PUMPED PROPERTY OWNER ADDRESS WHERE WORK WAS DONE GALLONS (R) RES[DeunAL <br /> 1 PLEASE INCLUDE STREET >r DIP,ECTION, STREET NAME AND C17V PUMPED (G) GR2 SF TRAP NAIUIEOFYTREATMENT <br /> CHEIACAL FACILLITYrTY <br /> city <br /> c�• u ��U� < < t� <br /> Cit ,r« U <br /> �n u I tc <br /> — t <br /> b � � cfty <br /> Yf i <br /> Gil L( ( S C( o <br /> m <br /> C <br /> C. c� 2 <br /> v L� M <br /> C- U C71 <br /> cityc_I o0 <br /> 0 <br /> C• <br /> C' <br /> Ci a' <br /> CI <br /> Page of <br /> EHD 42-09 <br /> i 2127113 _ <br /> SEPTAGE CLEANERS REPORT <br />