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z•: SAN JOAQUIN COUNTY - <br /> " ' ENVIRONMENTAL HEALTH DEPARTMENT <br /> ` 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Return this form by the <br /> 1 Telephone:(209) 468-3420 Fax: (209)464-0138 Web:www.sigov.org/ehd 12 of each month <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: ��� �� ) � /�f a. . S& <br /> �� Report for th o th of: / L ear <br /> Company Address: ,��,� i ^� <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 CHEMICAL <br /> CHADDRESS WHERE WORK WAS DONE GALLONS {R) RESIDENTIAL NAME OF TREATMENT <br /> PUMPED (3REASETRAP <br /> PLEASE INCLUDE STREET # DIRECTION, STREET NAME AND CITY C FACILITY <br /> 5�5 city <br /> City. <br /> Cit / <br /> i <br /> 42,2 L4Ji C ty 5% IC%4, sU�cJ <br /> Ci 1 / <br /> Cit <br /> y3 iyl�9 el �- <br /> Cit <br /> _ '7q at <br /> L�D � l) A7� / f� F l✓ ? cit / I <br /> � � c { <br /> Zd��; l%' /l//L 1i1/i Sid V L"1/ clt f ( ; <br /> a /V. 7%Jv Z o l— 'o . c; <br /> cit � <br /> • Lt�iC - � / '� cit '( <br /> 1iU OS <br /> City <br /> Al city <br /> _of <br /> EHD 42-04 " Page <br /> 12/27/13 <br /> SEPTAGE CLEANERS REPORT <br />