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ot4u1�•c <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 1868 East Hazelton 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 th of: l- year, <br /> Company Address: �3� '� ��— ) <br /> StreetAddressCity Zip Code <br /> - Signature: <br /> All information submitted must be Com tete, accurate, and legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAL <br /> PUMPED PROPERTY OWNER cREAseTRAP' NAME OF TREATMENT <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY PUMPED C) CHEMICAL FACILITY <br /> city. ! 1 <br /> eo JUS / P at <br /> �vlr �7'I C2S01' cit 9 f t L <br /> Cit <br /> —0 Z-.*/L Cit ! i 6;000 <br /> / ' y / G ✓� cit /( Dov <br /> U <br /> - '7� i-- ~j4V &ww-� Ci ) l /r�IJIJ f l <br /> Ge 45 ,9 X, ✓j'r-a Zt/z city L) t c l <br /> C ( <br /> ' ( / t / <br /> l <br /> city <br /> /C, ✓r/611 6-9ovo!� city <br /> City <br /> City /f a ov <br /> J�,✓Ib <br /> cit <br /> Pageof <br /> EHD 42-04 <br /> 12/27/13 SEPTAGE CLEANERS REPORT <br />