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s + <br /> '441ry' SAN JOAQUIN COUNTY <br /> )alfa-Cpm <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 1868 East Idazelton Avenue, Stockton, CA 95205-6232 12th 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: Report for the onth of: year ,:�?0/3 <br /> Company Address: //3��/�/ j `y��/Jp (,n¢. �� '�(� Signature: <br /> Street Address City Zip Code <br /> All information submitted must be complete, accurate, and legible <br /> DATE NAME OF BUSIIVESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R S ENTIAL NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED 191-2 REASE TRAP FACILITY <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY (C) CHEMICAL <br /> A �S0-402F A,'0Cit qed <br /> o <br /> /r 66 2% ��/ q—� w — Cit <br /> ,20 <br /> Ci r� Q.S //V�/ ��T�S/- <br /> .20 Cit <br /> �fl AOS -3,V3 0 /1/,911,1-1,'-T!W City L <br /> O�dr/�7J5', /7— .,QQ/ Cit <br /> 0 N� k�L Cit <br /> Cit <br /> Cit <br /> 7 Cit <br /> Cit <br /> C it <br /> Cit <br /> Cit <br /> City <br /> Cif <br /> E:7T <br /> Cit <br /> Page -5— of 5- <br /> EHD 42-04 <br /> SEPTAGE CLEANERS REPORT <br /> 12/27/13/13 <br />