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i <br /> ENTERED <br /> SAN JOAQUIN COUNTY � <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form bythe <br /> BOD East Main Street,Stockton,CA 95202-3029 Ir of each Month <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov,orglehd ' <br /> • 1• <br /> ' tL_ SEPTAGE CLEANER'S REPORT i <br /> Company Name: pomp Report for the month of: -g year Z-y0 <br /> Company Address: (7,s1� a. yqW4 signature: <br /> I~ SUWAddi&A city zip rode <br /> N All information submitted must be com late accurate and legible <br /> 0DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS RR) NAME OF TREATMENT <br /> i 111 <br /> PUMPED PROPERVOWNdt PUMPED G-JMTRM FACILITY <br /> PLEASE INCLUDE STREET S. DIRECTION, STRHET NAME AND CITY C LNEIaCAL <br /> N <br /> O <br /> m <br /> to <br /> ch <br /> 1_ <br /> a► C' <br /> U) <br /> Its <br /> Gityc <br /> IL <br /> E <br /> city3 <br /> D <br /> 10 <br /> +3 <br /> C CRY <br /> tU <br /> E C' <br /> C <br /> C' <br /> ttC <br /> W CRY <br /> MY <br /> city <br /> citym <br /> city <br /> m <br /> co <br /> 0 <br /> city <br /> W <br /> A C" <br /> O <br /> N <br /> EH0 42-04 <br /> IL 1014'07 SEPTAGECLI CLEANERS REPORT <br /> Gl <br />