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a r 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: )gov <br /> . .org/ehd <br /> .www.s' 12t" of each month <br /> ------------ <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: <br /> Company Address: ,j, �' f3 Report for the month of: .JJLI.tI <br /> � r ,� ,.vi�'�1-,-�, /� ., year C�/ <br /> Street Address Signature: <br /> � ✓ <br /> All information submitted must be com tete accurate antd le Ibte zfpcode— <br /> DATE / <br /> NAME OF BUSINESS OR <br /> PUMPED PROPERTY OWNER ADDRESS WHERE WORK WAS DONE <br /> PLEASE INCLUDE STREET ffi DIRECTION STREET NAME AND CITY GALLONS �R) RESIDENTIAL NAME OF TREATMENT <br /> PUMPED a AsE a <br /> C EMICAL FACILITY <br /> �VLYV ,Q� Cf <br /> -S• N r� <br /> J �� /moi 7- TIy cft l v�% t <br /> a c — <br /> CF S i��� I <br /> 0�3 , cit i 1 <br /> 02� > � i <br /> L- Cq <br /> GSI 1 <br /> Cit• <br /> SJNiC S%/tib✓ cit <br /> Cit <br /> a 7110 Z/77 ✓ /� %u <br /> t� O cit <br /> Cit <br /> Ci <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> EHD 42-04 <br /> 12/27/13 - Page _ Of <br /> SEPTAGE CLEANERS REPORT <br />