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SAN JOAQUIN COUNTY F, V <br /> Eta MRONMENTAL HEALTH DEPART4P� � Return this form by the <br /> :r fi00 East Main Street,Stockton,CA 95202-3029 l�t2e`of each month <br /> ti Telephone.(209)468-3420 Fax:(209)464-0138 Web:www.sigov.org/ehd FFB 01 <br /> SEPTAGE CLEANER'S REPORT LSH <br /> Company Name: NMN�pL , <br /> Report for� R year�_ <br /> Company Address: - (,- X y �40, lv Signature: <br /> 51reeE Address city Zp code <br /> M All information submitted must b Corn lete, accurate and legible <br /> mDATE NAME OF BUSINESS OR ADDRESS WHERE,WORK WAS DONE GALLONS 1R1 RESIDENTIAL NAlt1E OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED iG) GRe1Lse TRAP FACILITY <br /> w } PLEASE INCLUDE STREET f, DIRECTION, STREET NAME AND CITY {`, (,'{FYIC <br /> � <br /> IALO <br /> CRY <br /> ♦— <br /> C' <br /> C' <br /> G <br /> G <br /> city <br /> C' <br /> City <br /> C' <br /> CRY <br /> C <br /> C4 <br /> O <br /> L C" <br /> n <br /> ClJcity <br /> Cu <br /> CRY <br /> CRYti <br /> 0i <br /> rL EFO 4244 <br /> i 1014107 SEPTAGE CLEANERS REPORT <br /> m <br /> w <br /> LL <br />