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• QrgHth <br /> �.•vRra Oa' <br /> ���� SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 71 <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Return this form by the <br /> `''t �sa `� NOR 11 2017 Telephone:(209) 468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd 12 of each month <br /> ENVIRONMENTAL HEALTH SEPTAGE CLEANER'S REPORT <br /> Company Name: caE <br /> Company Address: J�jF �� Report fort m nth of: year <br /> Street Address J ? Signature: 1 <br /> City Zip Code <br /> All information submitted must be com p tete, accurate, and le able <br /> DATE NAME OF BUSINESS OR <br /> PUMPED PROPERTY OWNER ADDRESS WHERE WORK WAS DONE 3ALLONS (R REsin�t�T <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY PUMPED G �REASETRAa NAME OF TREATMENT <br /> C CHEMICAL FACILITY <br /> cit <br /> City .SCri <br /> oZ L 1 117 UVPia7i 0 D <br /> City Gf ods <br /> /Y/TY!-i _ 1621-10 <br /> Cit <br /> �/ Cit ( dG1 <br /> llqllqn <br /> � cit I r 5�L <br /> 0 17 <br /> rLDI-tl7c: Cit <br /> � - 0 Cit �D�'Tlrj/l10 <br /> Cit <br /> cit �S .. <br /> fld 6' a <br /> )3 /�-� <br /> k P�- z /a <br /> =WdO� `� �J�i S�yfdvG si//L T Cit it <br /> v <br /> �NG S �D / S J <br /> u yt/>✓ .A !n City <br /> �j(JcJ T� <br /> 04),r" to/() 'Lf/�Sj .� ���'!/9/✓��!/i=' city <br /> Sdd <br /> i 7, cit <br /> / 90G <br /> Cit <br /> EHD 42-04 Page Of <br /> 12/27/13 <br /> SEPTAGE CLEANERS REPORT <br />