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SAN JOAQUIN'COUNTY <br /> a; ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> 1868 East Hazelton Avenue, Stocldon,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 S'RC Report for the nth of:�dFrri'l3��I year . <br /> Company Address: ,/3, 7'i��E/J Q,��,n ,Q�,/ �¢ %� Signature: 71 <br /> Street Address city Zip Code <br /> All Information submitted must•be cam Tete accurate and le able <br /> DATE NAME•OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDEN71Al NAME OF TREATMENT. <br /> PUMPED PROPERTY OWNER PUMPEDOMASETRAP FACILITY <br /> PLEASE INCLUDE STREETS DIRECTION STREET NAME AND CITY C CAL <br /> city ' <br /> l'S' �%✓� S /yU' �lS <br /> City. o <br /> nJatJ Zk��15M m <br /> �5 � c��iiri i% cu OOv <br /> �/J In i T� cit <br /> A/ lnl)-i�v <br /> a <br /> 0( &&Zov�- I I 3 L. Ci <br /> ty <br /> ;f' IVW14 1411 ';� cit / �` ✓SCG <br /> ci <br /> % v�sL� crOs lit/ rrJ <br /> city !( <br /> BD X cS <br /> city <br /> Cltv <br /> PKIJ79BIA,774cS / X72191M lc`3"&I 1' Cit / J <br /> cit av zVe,c <br /> Cl <br /> Page of <br /> EHO 42-04 <br /> 12127/13 SEPTAGE CLEANERS REPORT <br />