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F ,a► ;..�Q RECEIVED AUG 1 7 2011 <br /> z` ti SAN JOAQUIN COUNTY <br /> _~ ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Return this form by the <br /> Telephone: (209) 468-3420 Fax: (209)464-0138 Web: <br /> 12 of each month <br /> www.sjgov.org/ehd <br /> Company Name: <br /> SEPTAGE CLEANER'S REPORT <br /> Company Address: ,/3 "_�F� Report for o th of: L year - <br /> � �% far ' � .�� <br /> Street Address � !City Zip Code Signature: <br /> All information submitted must be complete, accurate, and legible <br /> DATE NAME OF BUSINESS OR <br /> PUMPED PROPERTY OWNER ADDRESS WHERE WORK WAS DONE ](R,]RESIDENTIALPLEASE INCLUDE STREET # DIRECTION STREET NAME AND CITY GALLONSNAME OF TREATMENT <br /> SE TRAPPUMPED ICAL FACILITY <br /> /7Z✓imll <br /> city <br /> 942 <br /> ivN ou i/y//' i�a,4/v vi9,D Cit LiP'T�jt.e <br /> 850 /t c Cit y CS �2o <br /> 62 <br /> Cit <br /> 3� ` <br /> city <br /> "m <br /> City <br /> Y4190 r/ <br /> C Cit Ovv / i 1 / <br /> cit r <br /> Cit r ; <br /> Cit G <br /> cit <br /> ��� .mac, <br /> City <br /> its vU�s� <br /> o�Ss�o%u Cit G <br /> lr /a C?i /0 �1 Samoa C�Si,c� <br /> cit <br /> �,c'f�" C���Zee Ll,�l/'• cit � r , <br /> EHD 42-04 <br /> 12/27/13 - Page / _ 07 <br /> i <br /> SEPTAGE CLEANERS REPORT <br />