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0.p4 I ly. <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Rehurn this form by the <br /> Telephone: (209) 468-3420 Fax:(209)464-0138 Web:WWW.sigov.org/ehd 12 of each month <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: �iQC �" G�' ^/l��^ - � <br /> Report fort th of: 1/51vG <br /> Company Address:/ year oqv/ <br /> �'3- �fif=Gly �L <br /> Street AddresscitySignature: 7 <br /> Zip Code <br /> All information submitted must be Com tete, accurate, and legible <br /> DATE NAME BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS <br /> PUMPED PROPERTY OWNER (R) RESIDENTIAL NAME OF TREATMENT <br /> PLEASE INCLUDE STREET # DIRECTION, STREET NAME AND CITY PUMPED GREA FACILITY <br /> 1236 Wi df / TCit � � /�� CHEMICAL �g s <br /> rd( r�f �001? % ��� cit 9( k [I <br /> city <br /> �. at <br /> t r � <br /> If/11 rs o�y % o&;01i7r cit 201 X/ <br /> cityo? Orc) l <br /> ��r/y o20�3r �r� /jk Cit i t <br /> -Alit ri <br /> !E Ap ��,y /L OU/�1/� �� cityi I t c f j <br /> s a s �tl o 0 <br /> city ! 1 t l 1 <br /> (7/lf'��,�JS 3 JSjj E Ci <br /> Cit D � � 40 z <br /> �i[i(! S�- C °71.�a Cf/,�/��r Cit <br /> Cit i I t I 1 <br /> �' — <br /> �®f cit <br /> EHD 42-04 Page Of 6- <br /> 12/27/13 <br /> SEPTAGE CLEANERS REPORT <br />