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t4 �A SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HLALTH DEPARTMENT Return this form by the <br /> 9868 East Hazelton Avenue, Stockton, CA 95205-6232 12th of each mortth <br /> Telephone:(209) 468-3420 Fax: (209)464-4138 Web:vM,r.sjgov.orglehd <br /> SE TAGE CLEANER'S REPORT <br /> Company Name: Report fort o th of: year��� <br /> Company Address: 1 - 0� T— <br /> Signatur <br /> street Addre City Zp Code <br /> All information submitted most be Com P fete accurate, and legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK'WAS DONE GALLONS (R) RESmEi€iIAL NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER, PUMPED (G) CREAsETRAP FACILITY <br /> PLEASE- INCLUDE STREET k, DIRECTION, STREET HAMS AND CITY (C� CHEMICAL <br /> E- 1I �tr <br /> 00 CVL- cityS`R �r a1 <br /> +� 1 Ci" <br /> ea L6 p <br /> �{ u <br /> CRY <br /> ( ra <br /> Cit i a 7 .fl <br /> m <br /> C' c" <br /> 0 <br /> city z <br /> City Q <br /> 0 <br /> Cih, - ---- a1 <br /> Ci ' <br /> 0 <br /> Cit <br /> Cit <br /> Ci <br /> CID <br /> city <br /> C.• <br /> Page of <br /> j <br /> EH 42.04 SEPTAGE OLEAKERS REPORT _ <br /> rY <br />