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k. SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return thisform by the <br /> ti 1868 East Hazeltgn Avenue, Stockton, CA 95205-6232 12th of each month <br /> Telephone:(209)'468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: /}F <br /> ,Zlluel S'2Clot�}'J Report for them nth of: s year o?�'/ <br /> Company Address: /�3. r���� ��_ . 9r� 6.5 S Signature: � <br /> Street Address city Zip Code <br /> All information submitted must-be complete, accurate and le Ible <br /> DATE NAME OF 13USINESS OR ADDRESS WHERE WORK WAS DONE GALLONS I (R) RESIDENTIAL NAME OF TREATMENT. <br /> PUMPED PROPERTY OWNER °RF^s&TR^P' <br /> PLEASE INCLUDE STREET # DIRECTION, STREET NAME AND CITY PUMPED CHRiCAL FACILITY <br /> city <br /> city <br /> 774-8 4ox lqlF G city. <br /> cu ad' <br /> -6 6 '171 1hwINC cit 1�1D <br /> 7,Drt, 15�?4 W A&1�0 Cit J a tv x �-y <br /> 131 S -tel O/L 1 3--31V t'. city <br /> y t iF 2EGI A9 a Asr cmolwnlz Li&cit <br /> city <br /> O w lz AOcity <br /> l"y ZbL4.,b&X vf lVe /J/1. cit /1'1. <br /> le47city l <br /> ✓w-cel �3--/3o 410&71-J ci <br /> Tapp r'7✓}�( /�.�b l��%S%.�. T/t � - <br /> city <br /> 1 / 1itJl 1/t L%cs0Clic-I LE 1�i646 city J ..., <br /> S (� d tt LA&o 19 cit l . <br /> C�A�v� ct has' psi ���� . 61 /V:. 52�v <br /> Page of <br /> EHD 42-04 ' <br /> 12/27/13 SEPTAGE CLEANERS REPORT <br />