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RECEIVED <br /> 0.¢ � • SAN JDAQUIN COUNTY <br /> v <br /> 14 G 1 2018 ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> ` 186B East Hazelton Avenue, Stockton, CA 85205-6232 12th of each month <br /> rtq f a K;' ENVIRONMENTAL HEALTH Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/eh►d <br /> PERMIT/SERVICES <br /> SEPTA CLEANER'S REPORT <br /> Company Name: / 0 r L Report for the n h f• e V <br /> Company Address: ] Signature <br /> Slree Add ss CY,y Zip ode <br /> All information submitted must be complete, accurate, and legible <br /> DATE NA'PKE OF BUSINESS ORADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDEMIAL NAME OF TREATMENT <br /> PIJMPED PROPERTY OWNERPUMPED (G) G-REASETRAP FACiL.17Y <br /> PLEASE INCLUDE STR-EET P, DIREC71 N, STREET NAME AILD CITY tC R�,^, <br /> CHEAL <br /> / bIj <br /> Ct( l P U <br /> �o cc <br /> Ci <br /> 4 <br /> .10d Lfs a <br /> M <br /> cit• o <br /> c � <br /> Q <br /> Lk CL <br /> 0 <br /> c• <br /> r� <br /> Cit <br /> Ci <br /> I <br /> C' <br /> Ch, <br /> C� <br /> Cily <br /> Page of ~ <br /> EHD 42-04 SEPTAGE CLEAMERS REPORT a <br /> V <br /> 52127113 _ a <br />