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N RECEIVE® <br /> 1' �o JUL 2017 SAN JOAQUIN COUNTY <br /> mENVIRONMENTAL HEALTH DEPARTMENT <br /> L Return this form by the <br /> Ld ENVIRONMENT, '1868 East Hazelton Avenue, Stockton, CA 95205-6232 12" of each month <br /> � . ° ��a�` PERMIT/SERVICEHEALTH Telepiiorre: (209)468-3420 Fax: (209)464-0138 Web:www,sjgov.xglehd <br /> SEPTAGE CLEANER'& REPORT <br /> Company Name: // s <br /> O+"�� 915 <br /> / Report for the mo of: vitt year�� <br /> Gorr��Dany Address: ; O! i�osta-r IQo� <br /> '� �` 7S�S2 Signature: <br /> Strrxi Address Cify Zip Code <br /> All information submitted must be com lete, accurate, and Ie fibre <br /> ol <br /> DATE NAME OF BUSINESS OR <br /> PUMPED PROPERTY OWNER ADDRESS WHERE WORK WAS GONE GALLONS TTZ <br /> REATMENT <br /> U PLEASE- INCLUDE STREET 4, DIRECTION, STREET NAFAE AND CITY PUMPED LJTY <br /> Z <br /> ~J f o � ® �� Cil rc <br /> M �/ <br /> 3� <br /> �2 �I i <br /> O � 4� cil<1 4rfV4 <br /> Q ! CH /y!¢ �Iy �� <br /> / /��C/! v <br /> Sf <br /> (O,yv <br /> OCD <br /> cit Opp y <br /> Y93 <br /> CIA <br /> Lo city <br /> --- �. - -- - -- --- ---- ------ 3_�'� <br /> mCD o <br /> ��0� ��� /•t Cit i�Ci 6 N <br /> ef <br /> N �r t/.1 7� • Ci <br /> L0 � f - <br /> lz Cit 3 y4 �2 <br /> qy <br /> ��� 5r;Z ���-� 12� Cn <br /> N � <br /> a <br /> Page of <br /> f EHD 42-D4 — <br /> m 42/27113 <br /> v <br /> SEPTAGE CLEANERS REPORT <br />