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SAN JOAQUIN COUNTY <br /> ENVIRC?iJttiiGN7'Ai.IjL'ALlli DGPARIA4>rN3 Return this form by <br /> "'.. "-` 301 East Weber Avenue,3rd Floor, Stockton,CA 95202-2708 the 12'h of each month <br /> {,.) : y i Telephone:(209)468-3420 Fax:(209)461-0138 N�c6: wtvtiv.sj8nv.org/ehd <br /> ci <br /> SEPTAGE CLEANERS REPORT <br /> J I <br /> Company Name: 1 � L_ Y if � �— Report for the month of- �- year �� f r <br /> � f p <br /> Company Address;14 -�L. '' 'S Sign a ture-, <br /> Iscel Addrus U lily Zip Cade <br /> � All Inrurrnntion submitted must be rom leer, arrurute and legible <br /> [h (12? R£51l1[N'i'LSL <br /> ao DATE CAME OF BUSINESS Oil ADDRESS"'HERE WORI{RIAS DONE GALLONS (CI CRY.tBF:TRAP NA�IE OF TREATMENT <br /> C�lPUMPED PROPERTYo�rNF11 eLEASt INCLUOR STREET N. DIRECTION, STREET NAJI6 AND CITU PUMPED CI CnESIICAL FACILITY <br /> G <br /> 0 <br /> N Clay <br /> City <br /> Ci ' <br /> City <br /> City <br /> city <br /> MENTAL HEALTH <br /> city PEOM) <br /> Ciry <br /> Ciry <br /> iy <br /> Ci <br /> U <br /> Cily <br /> co <br /> rY City <br /> 0.'S — <br /> Q City <br /> t•ql�. <br /> m- <br /> 0) Cih• <br /> 0 �•! ('ilk' <br /> r <br /> co Ciiv <br /> C,L <br /> Q <br /> ScO�ir�Ces�w:d kepaa <br />