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RECEIVED <br /> RxY_ SAN.1�AQUIN COUNTY AUU 1 '), 2016 <br /> SA <br /> Return this form by the <br /> ENVRONMENTAL HEALTH <br /> 1868 East Hazels n Avenue, St ckton, CA195205-ENT 6232 NpPEQAr�AEN7qL HEALTH 12�' of each month <br /> .< PSERVICES <br /> Telephorre:(209) 468-342D Fax:(209)4640138 Web:VAIA+nr.sjgov.org e <br /> EPTAGE CLEANERS REPORT <br /> Company Name: Report for the hof: year <br /> Company Address$. ature: <br /> S€reet dress Gitp Zig Cade <br /> All rnformatron submitted most be complete, accurate, and legible <br /> (R) RESIDE <br /> GALLONS I.9TAL <br /> NAM!_OF 7REATMEPrT <br /> DATE NAIAE Or BUSINESS OR ADDRESS WHERE WORK WAS DONE PUMPED {G) caense TRAP FACILITYEA <br /> PUMPED FROPi=RTY OWNERPLEASE IYICLUDE STP.EET K DIRECTION, STREET T1AidE AitD,�CITY ( CyErLCAL .- <br /> c <br /> Z/14N� L` <br /> CIL- <br /> Cb <br /> -3 -712 iJ GlV Cil y CEJ Q �o <br /> u <br /> `L <br /> C� u !s 6v <br /> t c. <br /> 0 <br /> C; <br /> cao <br /> cit r.D <br /> Q <br /> cit <br /> c <br /> - Page . of <br /> _ S£PTAGE CLFAUER5 REPORT <br /> EHD 42-b4 <br /> U <br /> 12127/13 a <br />■ ■ ■ ■ ■ <br />