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SAN JOAQUIN•CC)UNTY <br /> b=. ENVIRONMENTAL HEALTH DEPARTMENT Return this.form by the <br /> 1868 East Hazeltgn 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: / C rS'2C L�yj i�/l Report fort e m nth of: year 0/ <br /> Company Address: <br /> Street Aadreee ep- <br /> Signature: <br /> City Zip Code <br /> All Information submitted must-be Com Tete accurate and legible <br /> DATE NAME�OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIOEN7IA—� NAME OF TREATMENT. <br /> PUMPED PROPERTY OWNER PUMPED eREASETnnr FACILITY <br /> PLEASE INCLUDE STREET A DIRECTION STREET NAME AND CLTY CNEIWCAL <br /> citySvc % r✓ / S�� S' L'� <br /> city <br /> s�7in/ l 6 sr 1.�f/E <br /> City. <br /> city <br /> LEIAII(j Lo eov6 TA Ni f�i9�I�Zrr/ cit <br /> CltvA� - <br /> ,s cit <br /> s- / D l/11 S¢6u T i4 a0 <br /> cityywU <br /> cir7fly 101 7 01 <br /> as-reo iUN1c1Gs/J!e yn. PW Zd SceW" city <br /> W o (dGtiiD ,E / 6 3% , LR1l F <br /> 0lq-,o - city % ,f- <br /> 61ty <br /> Page - of <br /> EHO 42-04 <br /> 12/27/13 <br /> SEPTAGE CLEANERS REPORT <br />