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<D <br /> SAN JOAQUIN COUNTY <br /> 124 0' ED Return this form by the <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> ENTERED <br /> Telhone:(209)468-U2-10 Fax.640 East Main Street.. Stockton,CA 95202-3029 12' of each month <br /> -0,10 -(209)464-0138 Web:WWW.&jgov.orgVehd <br /> A <br /> L ep <br /> EMIRONMENT �EAJH SEPTAGE CLEANER'S REPORT <br /> Company Name:pt�-t Report for the m9pth of: L/ year <br /> Company Address: .5AX-ICNM '?5701 Signature: <br /> 'SireetAdaVess city as Code <br /> All Information submitted must be r-offlPlete. accurate, and lizqi(file <br /> ADDRESS W14ERE WORK WAS DONE GALL NAME OF TREArMENT <br /> I a pqjMpFD (6) GREAIETW FACILITY <br /> PUMPED PROPERTY OWNER —t <br /> (RI V01012NMAL <br /> DATE NAME F BUSINESS OR OHS <br /> ;-LFASE IrSCLUDE STREET 41. DIRECTICK. STRgET RAKE AND CITY (Cl CHEMICAL <br /> C* :5Te <br /> 7 'S <br /> - <br /> -'L Z. Cift .57e'e-lc ftlpi /'2 e.e) 6- <br /> Of 3- <br /> .1ry�ll -439A & <br /> rohne� t' <br /> cr, -7 4o Y e- /Z-c,,L <br /> r13 <br /> C:P I sz cc z CN 570 CK&n <br /> w <br /> co <br /> Y-of (dell U 7 0 ix aly S7 0ace-en <br /> 1V4'Q0'1e- AC/' -T <br /> 4'9 'e' r CA-) <br /> 33 9:1 1112 S <br /> Aj a5354,crC7c:n 381 mac_ S <br /> QC? 3 S- E - MS-Tae-(Z-70,,7 125�',00 <br /> o Y /,v,,L Ivun6,re- /I 4 q ye" !c-h j'r,or-- � c4y -Vat-1z7v r') t,:z 0 0 <br /> Lj-C-Ce S&,-JZ- P,,rt <br /> t�r� city <br /> (-ermrvj*.'; 7711."69 127 i I Th ee^+" Cfty, 37 v cc-r a x) i&00 <br /> 1 City -s-TC /ap60 <br /> L <br /> -70 L -7 -4- <br /> City s-rocycre,-2 <br /> 12- <br /> q- e <br /> C� cft �jr.cjen I <br /> "i L-EHD 42-04 SE)PTAGE CLEAFERS REPORT <br />