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� x n SAN JQAQUIN COUNTY <br /> ENVIRO1JrOjENTAL HEALTH DEPARTMENT Return this form by the <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 12'h of each month <br /> Telephone:(209)4£8-3424 Far (209)464-0138 Web:wvnnr.sJgovorglehd <br /> ,Fa•� <br /> SEPTAGP CLEANER'S REPORT <br /> Company tame: Report for the o of- year <br /> Company Address: ��`;F�ignature: <br /> S€refftCay 2iy Co a <br /> All information submitted must be complete, accurate, and le ible <br /> (R) tZESMFt=L <br /> DATE NAR[E OF BUSENESS OR ADDRESS WHERE WDRK WAS DONE GALLONS NAME OF TREATMENT <br /> (G) clasETeap FACILITY <br /> PUMPED PROPERTYOYYNER PUMPED <br /> PLEASE INCLUDE SlIZEE P DIR TION, STREET 4kpr= AN CITY (ClCNEWAL <br /> C' <br /> (),YM <br /> u (] p7ir-1y c- ZV <br /> LC 'c <br /> City db <br /> Q It u u <br /> h r C, t ` tt <br /> MIN b 1 l 4 m <br /> �- <br /> .3 SS o <br /> i <br /> city <br /> s t-ti <br /> C , i s o` <br /> 1 <br /> Gity <br /> �.; <br /> C4 <br /> C <br /> CrL <br /> Page of <br /> FEB 0 3 2016 <br /> a <br /> Ho a2 na ENVIRONMENTAL HEALTH SEPTAGE CiF1ANERS REPORT <br /> 17113 PERMIT/SERVICES <br /> ii■ii■ <br />