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,A- SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 600 East Main Street, Stockton,CA 95202-3029 12'"of each month <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web:WW5111.S19ovorg/ehd <br /> GL SEPTAGE CLEANER'S REPORT <br /> Company Mame: _ R"'0771am :Z7/lc - Report for the mon of: U� year Zoo�f <br /> m Company Address, 0 6OX /-/5,00 5zlZ(nC1S CA gS011� Signature: %IC aY� 1 <br /> C5 s(rsetadd City Zip code <br /> 0 <br /> z <br /> All information submitted must be complete, accurate and legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DOME GALLONS (R) REMIDENnAL NAME OF TREATMENT <br /> PUMPED PROPERTYOWNER PUMPED {G} GREASESRAIX FACILITY <br /> PLEASE INCLUDE STREETS, DIRECTION, STREET MAIIE AND CITY jr-) ��� <br /> Lat710110 a ��Z r� C 0 <br /> z U S C1/? rfp ., city 3 o <br /> (O V 9L-uL 5 <br /> C' <br /> C <br /> C <br /> Cft <br /> c� <br /> CRY <br /> z <br /> Y <br /> U <br /> Q <br /> w _ <br /> CL- <br /> city <br /> d <br /> CRY <br /> City <br /> CRY <br /> LSl <br /> Q <br /> 4 <br /> CV - <br /> C-i <br /> ch <br /> U <br /> LU <br /> a EHD42-04 <br /> 1014X7 SEPTAGE CLi NERS REPORT <br /> pf4J(i <br />