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SAN JOAQUIN COUNTY h G I•M t12-'h:of <br /> ENVIRONMENTAL HEALTH DEPARTMENT :each <br /> is form by the <br /> 600 East Main Street, Stockton, CA 95202-3029 0 '� zp14, month <br /> `� Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sigov-org/ehd <br /> SEPTAGE CLEANER'S REPORT ENVIRONMENTAL HEAL- <br /> Company Name: Report fo'� �T�ii�tith of year�1y <br /> Company Address: / U-B --K yy� ,�.-4 1 Z- 953�� Signature: <br /> Street Address City Zip Code <br /> iii All information submitted must be complete, accurate, and legible <br /> r.-) <br /> 1-HDATE NAME OF BUSINESS OR RESIDENTIAL <br /> C1 <br /> PUMPED PROPERTY OWNER ADDRESS WHERE WORK WAS DONE GALLONS (R) NAME OF TREATMENT <br /> PLEASE INCLUDE STREET i, DIRECTION, STREET NAME AND CITY PUMPED (G) CHEMICAASE L <br /> FACIL Y P <br /> � t C CHHEMICAL <br /> 0 <br /> Cit <br /> city <br /> City <br /> city <br /> 0 <br /> city <br /> LL <br /> c <br /> I`1 <br /> Ci <br /> CU E <br /> Ci <br /> it <br /> lU -- <br /> �� EHD 42-04 <br /> 1014/07 SEPTAGE CLEANERS REPORT <br /> _J <br />