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JAN 1.8 26 <br /> ENVIRONMENTAL HEALTH <br /> sem• PERMIPSERVICEr <br /> SAN JOAQUIN COUNTY � • <br /> b! ENVIRONMENTAL HEALTH DEPARTMENT Return thiS.form by the <br /> 1868 East Hazeltgn Avenue, Stocldon,CA 95205-6232 12th of'each month <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web-www-SJgovorglehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: V / C S'�� G iGul Report forAttheonth of: 8 year7Company Address: Signature .�� a�T <br /> Street Address City Zip Code <br /> All information submitted must-be complete, accurate and le able <br /> DATE I NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R RnlbENML NAME OF TREATMENT. <br /> PUMPED PROPERTY OWNER PUMPED )° SUAAP, FACILITY <br /> PLEASE INCLUDE STREET p DIRECTION STREET NAME AND CITY C CHEMICAL <br /> city a,U D dvc�i�JO/l.�s l <br /> city i f <br /> )Yl�/1i 7$ 0 s• l <br /> city, <br /> �-� _ P v� i a y� i2i� cit <br /> cit <br /> C Cru i�vZE�J J 3 SS o11&76/j IT— cit /4 v�L <br /> �', 'i✓��v vur Irl �,c '(orS GU�Si �ir�/ <br /> city <br /> 610 city <br /> YAFA) El;r)A/t , ///� (/V k�i�� ca`YY9D1/LCit l l r <br /> <evri 2GAl _ / 3 S .S�7beK-coatJ <br /> c1tvl' tJc7 <br /> zie c2v ci <br /> Itg <br /> 2,0 cit"y <br /> NX19-CwAS`_ <br /> Cit <br /> Iry �- awes �.. <br /> cu / Ulla <br /> Page I— of <br /> EHO 42-04 <br /> 12/27/13 <br /> SEPTAGE CLEANERS REPORT <br />