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SAN JOAQUIN COUNTY <br /> "! ENVIRONMENTAL HEALTH DEPARTMENT Return this.form by the <br /> ''�. `• 1868 East Hazelton Avenue, S1:ocldon,CA 95205-6232 <br /> Telephone:(209)'468-3420 Fax:(209)464-0138 Web:vwvw.Sjgov.org/eht� .12th of'each month <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: <br /> Report for the onth of:S� year <br /> Company Address: 1�.�, r�F�al� , ,,,�,, „f <br /> SheetAd*ess cid, 70 Signature• <br /> Zip Code <br /> All Information submitted must-be com lets accurate.- and le ibis <br /> DATE N ME�OFPROPERTY <br /> BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R 81D "L <br /> PUMPED PROPERTY OWNER oREAss NAME OF TREATMENT. <br /> PLEASE INCLUDE STREETS, DIRECTION STREET NAME AND CITY PUMPED FACILITY <br /> 7/ CNEMICAL <br /> La,V lc.-,9� city L��lJ,L/ 5 LCi � �C`'/lz: <br /> CKP <br /> Vllo •G,s P.� l OSD T�dUi lD l� <br /> city <br /> �� GrJ�ti' r• Q%!2 L17v1/ cit / I <br /> • C-k ll •5-657/U Ai�Se)%6 cit <br /> Y h ✓ ci > l J OJ <br /> cit l <br /> cityCit �l <br /> > � CSL) <br /> sZ01 CR <br /> /fir rlmins <br /> Ci jl <br /> /r r9�%GL i2�'I� 4/to'✓�?JGU �l1/�.G) <br /> City > - l <br /> t Z2 <br /> �nV,q�C�SSZ�J t l <br /> EHD 42-04 Page ' of <br /> 12/27/13 <br /> SEPTAGE CLEANERS REPORT <br />