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SAN JOAQUIN COUNTY <br /> RECEIVE® <br /> z ENVIRONMENTAL HEALTH DEPARTMENT F , Return this form by the <br /> 600 East Main Street, Stockton, CA 95202-3029 ' i 12°h of each month <br /> Telephone:(209)468-3420 Fax:(209)464-0136 Web:www.sjgov.orglehd <br /> a SEPTAGE CLEANER'S REPORT ENVIRONMENTAL HEALTH <br /> , // PERMITISERVICES ���jjj 2 <br /> Company Name: I //i nTii^ - Z LCL�n ri �G Report for the m f: year,,20 <br /> Company Address:Z-0 4X9 r 7�1� LhG ✓ /� 3�� Signature: <br /> street Address cM ZZp Code <br /> All information submitted must be com iele, accurate, and legible <br /> 'p <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS IRI N"5AU" 1AL NAME OF TREATMENT <br /> N <br /> PUMPED PROPERTY OWNER PUMPED (G) eREASETRAP FACILITY <br /> m 1 PLEASE INCLUDE STREET /. DIRECTION, STREET NAME AND CITY C CHEMICAL <br /> V <br /> city <br /> V <br /> City <br /> Cft <br /> O <br /> F- <br /> C' <br /> C' <br /> City <br /> C <br /> ) C <br /> C <br /> l C. <br /> C <br /> City <br /> F'. C <br /> O, <br /> C <br /> �I <br /> O� C' <br /> CAY 4 <br /> mi <br /> tU I <br /> fL EHO 42-05 SFPTAGE CLEANERS REPORT <br /> i <br /> taam <br /> ml <br /> W i <br /> U- <br /> I <br /> 1 <br />