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i:Nun?0�FNPAL HEALTH DEPAMIEN Return this farm by <br /> 5txeet Stockton,CA 9520-2708!!�� 7 p 3 the 12*of each month <br /> > "' `• Telephoaae. {2Q9)%#6$-3420Yrx;{2o )464.013 Web:xn�+x.sjov.er�eh <br /> t t 5 ��i{~)�r CLEANEir S. Epo r <br /> ? <br /> Company Name: VVI)Z,I, avY l i I l s�� <br /> P. y. ReporCfor them th of_ year <br /> U. , <br /> Company Address: GIU {�'y t� � (�� C �! �" Signature: 4LULC&M <br /> Scmee Address City Lp Q)dc <br /> All information submitted roust be complete, accurate, and legible <br /> DATE NA.E ORRUSIPfE.SS OR ADDRESS WHERE AVOWWAS DONE GALLONS �� RPSITISNI7AL NAME OF TREAT MINT <br /> PUMP) PROPERLY OWYER PUMPED (G) GRYASE iRL&P FACILMYY <br /> PLVASE iNCLUDE STREET A, Dmxcriox, STRtEr NAME AND CITY (C) CHEMICAL <br /> (LL aty <br /> 610� 6 �Q -P1 s�j 1 .tom. An-1_51is , <br /> t { �� iI.�Ct.!' t-- '�' C' iZ - 7 <br /> ciq �� r61 YG4L• 4� (�.� <br /> 51 b is I'Yl, l ra Mmj' ai, lmcZ% - TradtOD'eY <br /> Stor . i'�iii ,t I L K?S ' - t�e G <br /> also <br /> City <br /> °� �(3 f �t LCR, `l� — "4 t cis <br /> 1_. v� ?? �� --{�t- city !1/Itit 71 {'CAL— <br /> z <br /> t2d, i he.,,C . 7 { l ti i1011 PZ1 Aty�' ss C� <br /> 1,f <br /> r' c 1 C' LtL GfJ1� o <br /> �L lz at, &5.W Y 9 wb JE_- (l 4�Y L Ci r t (2) i` E" 1.cc <br /> NG 4 5; Y ! C ..�tom,cat.. DI) k)4 CF- <br /> rtz: „� a xl � .f _ r` r11&t,v� .. �' j ( �a (1G' �L. <br /> aty <br /> r>h <br /> c1fC' <br /> N <br /> o > <br />� EHD 42-04 $epticJCesspocl Report � <br /> F <br />