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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH iDEPARTMENT Return this form by the <br /> 600 East Main Street,Stockton,CA 95202-3029 1 e of each month <br /> Telephone: (20)468-3420 Fax.(209)4640138 Web:wrww.sjgov.orglehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: IIIA( Aiuk;W4 —7-1t e - Report for the meront of: & ril ye-2,d <br /> Company Address: f 'G U �� f �S /� �v`�/� Signature: <br /> Steel Ad&ess city ZP Code <br /> 0 <br /> All information submitted Must ba Complete, accurate and legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS " "W°""A' NAIVE OF TREATMENT <br /> PUMPED PROPERTY OWNER pUMPHD (G) ow-mETRAP FACILITY <br /> PLEASE INCLUDE STREET P, DIREGTIDN, STREET NAME AND CITY C CHEMICAL <br /> 2' J1.1 CSV � C A Ci 55 <br /> a7 0 s CMZ t �-I u1 �nfD <br /> 2 �I C157V <br /> U 9 X11, W-w v `- city 14C o <br /> o 0f(& n I GozL CA -) <br /> Chy <br /> Ci <br /> C ply <br /> U C' <br /> Q <br /> C <br /> city4 <br /> CRY <br /> r� <br /> Ci <br /> CRY <br /> rn <br /> 0 <br /> 0 <br /> N <br /> Cfty <br /> ca <br /> Lu <br /> EH©42.04 SEPTAGE CLEANERS REPORT <br /> 10lAfD7 <br /> .r. <br />