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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Return this form by the <br /> Telephone: (209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd 12 of each month <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: I (fJ. ���s, <br /> �• Report for th of: year,:;?, ()/,5 <br /> Company Address: .a�S� �� � �5� %� Cy' <br /> Street Address City i�Zip Code Signature: <br /> All information submitted must be Complete, accurate, and legible <br /> DATE NAME OF BUSINESS OR <br /> PUMPED PROPERTY OWNER ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAL <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY PUMPED cREASETRAP NAME OF TREATMENT <br /> C CHEMICAL FACILITY <br /> AV/0 Gu ef <br /> lc7z2 v(/ <br /> City Sad <br /> city / <br /> Cit <br /> cit // 6-) <br /> �ezioni ro <br /> � � pig cit i <br /> Cit / <br /> i l <br /> at / l <br /> 13a D ,b) Cit �� v �► ! � <br /> ✓I/ V _ cit I I 7• l <br /> e Zf i-SD ci <br /> cit i <br /> cit !( / <br /> City <br /> Ulie✓b 6�0 R 915 Cit <br /> Dilc7 44 <br /> —of <br /> EHD 42-04 - Page <br /> 12/27/13 <br /> SEPTAGE CLEANERS REPORT <br />