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o R SAN JOAQUIN COUNTY <br /> EwARONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 600 East Main Street, Stockton,CA 95202-3029 1th of each month <br /> C-4 Telephone:(209)468-3420 Fax:(208)464-0138 Web:www.ajgov.arglehd -1^ -17— .SEPTAGE CLEANER'S REPORT J.-T, <br /> Company Name: ple4w i YL[ - Report for the month of: year 2e-7� <br /> I.n ° SCompayAddss: c Cm ' lSignature. <br /> 0 5tr"Address Cw Zip Coda <br /> C=5 All informatlan submitted must 6e complete, accurate and le [ble <br /> DATE NAME OF BUSINESS OR ADDRESS WHE;RE WORK WAS DONE GALLONS (R) RESIDENTIAL NAME OF TREATMENT <br /> PUMPED PROPEFMdWNER � PACIL4TY <br /> PLEASE INCLUDE STREET A, DIRECTION, STREET NAME AND CITY PUMPED {�f Cl¢IMAL : <br /> 0 u 6 O _W s 0I/ A ft';73 <br /> wv <br /> iY4Wawa <br /> 54 , <br /> et <br /> cfty <br /> ca <br /> CRY <br /> c� co <br /> cftyU <br /> Q <br /> d C. <br /> ME <br /> l C' <br /> CRY <br /> CRY <br /> C <br /> CCC> C <br /> ityCRY <br /> C <br /> 0 <br /> N <br /> _ C <br /> ftvU <br /> � EHD 42-04 SEPTAGE CLEANERS REPORT <br /> 10�41U7 <br />