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4. SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> ` I 6 D East Main Street,Stockton,CA 95202-3029 121° of each month <br /> {: ? Telephone (208)46"420 Fax:(209)464-0138 Web:www.sigov.org/ehd <br /> d SEPTAGE CLEANER'S REPORT <br /> Company Name: LC . C ' "e. a. 2 f:�77 : <br /> year <br /> CC> CompanyAddress . <br /> r� tul <br /> 81reet Address City Zip Gods ' <br /> o All Information Submitted must be complete, accurate, and legible <br /> cRf 4ESIOEHTAL <br /> DAVE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS FIANCE OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED (GI GREd6ETRAP FACILITY <br /> PLSASE INCLUDE STREET 0, DIRECTION, STREET NAME AND CITY C) CHEMICAL <br /> AX {/ C[ty <br /> CRY <br /> C' <br /> city <br /> city <br /> city <br /> city <br /> City <br /> city <br /> City <br /> Gi <br /> City <br /> e <br /> � c <br /> Q <br /> city <br /> cs <br /> Q <br /> q <br /> city <br /> G1i <br /> City <br /> N <br /> 7 <br /> 0 <br /> z EHD 42.04 SEPTAGE CLEANERS REPORT <br /> TW407 <br />