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k <br /> t <br /> SAN JOAQUIN COUNTY <br /> s" ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> -ti 9868 East Hazelton Avenue, Stockton, CA 95205-6232 12th of each month <br /> Telephone: (208)468-3420 Fax:(209) 464-0138 Web:WV.AY-sjg0v.org/ehd <br /> / SEPTAGE CLEANER'S REPORT <br /> Company Name; ! Re ort for the <br /> p oath of: year 115 <br /> Company Address: <br /> S Signature; <br /> met Sd res= rty J Co3e <br /> All informat[oo submitted must be Com tete, accurate, and legible <br /> GATE NAME of BtY OWN NE GALLONS s OR <br /> PUMPED PROPERTYOVJNADDRESS WHERE V%'ORK WAS DO (R) RESIDEtl7IAL <br /> ER NAME OFTREATMENT <br /> PLEASE INCLUDEE 57REES P, DIREC710N, STREET NA"E AND CITY PUMPED (C) CHEMCAL(G) csEasEraAr FAClL[TY <br /> coy J <br /> '^ citt f c 4 ! ( t <br /> ` YI' <br /> rvy y SJ�S 'YI'� Ky o b Lt <br /> -� `✓ - <br /> City L <br /> o��fr <br /> tt - <br /> `l Cr). <br /> cM <br /> r} � y't`�G � 6 b t o <br /> , _ C1r• �_ � s I �-, <br /> cel l .2a0 6 'I <br /> t,t � <br /> U� city <br /> _ I <br /> Cd <br /> cit, tt .2,aop ll <br /> c <br /> c' <br /> Page of <br /> EHL)42-V4 <br /> 1212711' SEPTAGE CLEANERS REPORT <br /> ■ ■ ■ ■ ■ <br />