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at�Kln s SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 1866 East Hazelton Avenue, Stockton, CA 95205-6232 12t' of each month <br /> � Te(ephone:(209)46B-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd <br /> �a <br /> CSEPTAGE CLEANER'S REPORT Report foe the Oh O . ye r <br /> Company Name: / <br /> Signature: <br /> Company Address: Set Addrestasty co e <br /> Street <br /> All Information submitted must be corntete, accurate, end legible (R) RESIDVaLAL <br /> ADDRESS WHERE WORK WAS DatdE GALLONS �O' ca EASE TRAP NAME OF TREATMENT <br /> DACE NAME OF BUSINESS OR PUMPED FACILITY <br /> PUMPED PROPERTY OWNER PL-EASE INCLUDE STREET K, ❑IRECTICU, STREET HAILE AND CITY (C) CEEMICAL <br /> lei2 city <br /> � �{ � <br /> � � <br /> ! Clt <br /> a0c) Lk <br /> a 4 <br /> L` <br /> ciky <br /> ci <br /> C ck <br /> 0 <br /> Le <br /> a—i7i; tAAZT CCD <br /> k cityo <br /> U <br /> u Glt <br /> q <br /> irn <br /> Cit <br /> C" <br /> G" o <br /> co <br /> Ci. <br /> c <br /> N <br /> Page Df <br /> iSEPTAGE CLEANERS REPOP.T — <br /> EHD 42-04 <br /> 1211 a' <br /> rY <br />