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oi _ <br /> ECEIVE® SAN.IOAQUItV COUNTYMAR 0 7 2019 ENVIRON14ENTAL HEALTH DEPARTMENT Return this form by the <br /> 3868 East Hazelton Avenue, Stockton, CA 95205-6232 92ff' of each month <br /> _NVIRONM€NTAL HEALTH Tefephone: (209)466-3420 Fax:(209)464-013B Web:vrww.sjgov.orglehd <br /> PERMIT/SERVICES <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: r s `�CG Cit` Report forth m. th of: ypr 615' <br /> Company Address: q S� Signatut <br /> Stee4 Ad4ass city Zip Cade <br /> All Information submitted must be complete, accurate and le fble <br /> DATE NAME OF BUSINESS OR ADDRESS W14ERE WORK WAS DONE GALLONS (R) RFSIDBMIAL NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED (G) eters T" FACILITY <br /> PLEASE INCLUDE STREET 9, 01 CTION. STREEZ NAME AND CITY C) C}IS9CkL <br /> -5 2 c s SPI <br /> City F E 6 <br /> _ C �t <br /> t / l zS' leo <br /> etty <br /> C' <br /> r� <br /> C' <br /> CPY0 <br /> city <br /> CRY <br /> r� <br /> C <br /> 0 <br /> c� <br /> C' <br /> City <br /> i <br /> city <br /> Page of <br /> Eia 42-04 <br /> SEPTAC-E CLEANERS REPORT <br /> 12127113 � <br />