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SAN.JOAQUIN COUNTY <br /> e? ENVIRONMENTAL HEALTH DEPARTMENT Return thfs.form by the <br /> 1868'East Hazeltc(n Avenue, Stockton,CA 95205-6232 12th of each month <br /> Telephone:(209)'468-3420 Fax:(209)464-0138 Web:wwW.sjgov.orglehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: - S'f2C G i�/C Report for the month of: �,� l c year__�6,'i _ <br /> Company Address: ��3 Epw �lr , ,sh 654 -� <br /> Street Address i—� City Zip Code Signature: �( ✓i Z /tt�/�� <br /> Ail Information submitfed must-be complete, accurate and legible <br /> DATE NAMEoOF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAL NAME OF TREATMENT. <br /> PUMPED PROPERTY OWNER PUMPED eREASETRAP FACILITY <br /> PLEASE INCLUDE STREET i{ DIRECTION STREET NAME AND CITY CHENgCpL <br /> 77/7 ' mu /ill J 5- �f cit, TiL �r (JlJ[J v�.¢D�Gd SSS <br /> 804114 A/7 A %/i/C 6Al- lYl �T� i� city > <br /> City. /l <br /> cit <br /> &W k Int /b i eV'2 ,-�— cit <br /> Az?'q-tE ev 3 a Wl i)YL77) /U'1)/L/ 20; <br /> 'City <br /> As 7lri5 cit <br /> city <br /> L ill ;z 1/7S^W, 0(✓�M rAE- city <br /> Susi' (/iA U&tl 2Ll cit <br /> y7S—GU- 0/lfirni j <br /> cityl�U <br /> 1 '7 , 1n,3-ii?d �SiA�' cityu/� 0 <br /> o✓br/ � city <br /> ►rtI <br /> city <br /> c ���� / 5 GCS <br /> cl , <br /> Page of <br /> EHD 42-04 <br /> 12127113 <br /> SEPTAGE CLEANERS REPORT <br />