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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> �1 600 East Main Street,Stockton,CA 95202-3029 /12k1i of each,month., <br /> Telephone:(209)4683420 Fax:(209)464-0138 Web.www.sjgov-orglehd '� I � � ° ,V 4��� <br /> SEPTAGE CLEANER'S REPORT CC <br /> Company Name: IP Al.,11 C 1 '/�t- Report for the month of: U year <br /> CompablyAddress: &J/ �� ll?aS CIES' Signature: 4&1"zad e <br /> CD Srreet address CRY zo Code <br /> C3 Ail inrormatTon subrnitted must be complete, accurate and legible <br /> DATE NAME OF BUSINESS OR ADDRESS W14ERE WORK WAS DONE GALLONS (R) FEM°M14- NAME OF TREATMENT <br /> PUMPED PROPERTYOWNER PUMPED (G) emmETRAP FACILITY <br /> PLEASE INCLUDE STREET It, OIRECTIDN, STREET WAKE AND CITY . <br /> C CHEMICAL <br /> zl ,-1 -;-Iun d / W105-1 AwL71A cAncqv a <br /> o-1hflr <br /> 6(17 CJ aIn . ofty <br /> city <br /> CKY <br /> CRY <br /> CRY <br /> city <br /> z <br /> aty <br /> Y Ci <br /> Q <br /> C' <br /> C <br /> CRY <br /> city- <br /> a <br /> rn <br /> oofty <br /> 0 <br /> C <br /> N <br /> U <br /> a EHO 42-Q4 SEP7AGE CLEANERS PX"RT <br /> 101447 <br /> —._ ._. ... -....._ _.........- <br />