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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 600 East Main Street, Stockton, CA 95202-3029 APR 01 2013 12�h of each month <br /> < Telephone: (209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: L LaZZ:�'a X=d4 Report for'the month of: year 2O1 5 <br /> Company Address: Signature: <br /> Street Address City Zip Code <br /> All information submitted must be com lete, accurate, and legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAL NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED (G) cR�LSErRaP FACILITY <br /> OD PLEASE INCLUDE STREET f, DIRECTION, STREET NAME AND CITY C CHEWCAL <br /> ,D <br /> city <br /> O <br /> C; <br /> C' <br /> C' <br /> CRY <br /> CRY <br /> Cay <br /> C' <br /> C'" o <br /> cv <br /> r— <br /> o <br /> n C' z <br /> city <br /> city <br /> m <br /> City m <br /> 0 <br /> CRY C-' <br /> E <br /> O <br /> fy CRY <br /> L� <br /> n citya <br /> ni Q <br /> Citya <br /> CD – <br /> C ity1— <br /> M <br /> O EHO 42-04 <br /> 10/4107 SEPTAGE CLEANERS REPORT a, <br /> I a <br />