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' I <br /> Qe.4ut'y' ° SAN JOAQUIN COUNTY REC 'V <br /> FD <br /> ` ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 1868 East I-lazelton Avenue, Stockton, CA 95205-6232 JUL 14 2014 12th of each month <br /> V . a Telephone:(209) 468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd <br /> ENVIRONMENTAL HEALTH <br /> SEPTAGE CLEANER'S REPORT PERMIT/SERVICES <br /> Company Name: /GV Report for thp,4nrth of: <br /> � earl viz <br /> Company Address: Signature: <br /> Street Address City Zip Code <br /> All information submitted must be complete, accurate, and legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAL NAME OF TREATMENT <br /> -6- <br /> PUMPED UG REAE TRAP - FACILITY <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY (C) CHEMICAL <br /> cit i sc v /mac �ts <br /> SqV D C .56 /`(J City J <br /> i� oAlI-) city < < < <br /> rnvN i f Jd 20 TWO/ 0 City ft <br /> cit <br /> cit <br /> s ih City / <br /> S), 60GD �5 oS• Lf}2/to ��� Cit <br /> c .CL)oi 5T/3,)iv cit <br /> 6'(�-ccc /30/ So city ) ,, r r <br /> G RvQESs os Rt��� cit ii <br /> �65aw0D 61VII i,(f SLDmo0 Cit Irl <br /> 6�i7`c� l0/ / / /� S" ^/� C, cit //56.'0 <br /> "C v C Lo Co 75v A yo S' cit <br /> iLAW /yam d.5 " % at <br /> W Bi ✓ 973 cit <br /> Page J of <br /> EHD 42-04 SEPTAGE CLEANERS REPORT <br /> 12/27/13 <br />