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$AN,IOAQEQN COUNTY RECENt <br /> I <br /> Et{1t1RONMRNrAL HRALTH DEFAKTN1hWF Return this form by w <br /> 394 Bast We= 3"Floor,Stoo AN �9 2013 the 12°of eac►moat► ° <br /> m ue ldao C A 91202-2708 <br /> ti <br /> Telephone: (209)468.3420 Far(209)464-0L38 Web:www.ggov,arglehd a <br /> m <br /> SEPTAGL CLEANER'S REPORT ENVIRONPERMMENTALHESLT <br /> a Ctmlpany flame: 1 _� __ Report for the month of_Aaa Pn gear <br /> CompanyAddreer. ��`�i l c��` 'i�� Signature: <br /> fN,rs. 4ea City L'yCcda <br /> All lato[maliea submitted muss be [om lete [eturele and legible <br /> DATE N"IEOFBUSIMMOR ADDRESS VMRR WORK WAS D ONE GALLON'S IR' "Esmrw7uf. <br /> (Ly OREM[neu ]NAME OFTREATMEM <br /> FtII�HD FROPER't\'OWtiER It-[AA[ INCLUDE STREET [, DIRECTION, STREETPBD' NAM[ ♦ttD 'ITT PiM01ma PACILITY <br /> 2 I p1 at, 2 <br /> i <br /> X, 2 3 pfi N «, <;4 <br /> i2 <br /> � Q <br /> o: r a <br /> a <br /> 0� as 20 t2 N <br /> Qty 12-Ob <br /> �✓n� <br /> City J2w <br /> YLG. a" Zi�D ' 12 <br /> [ <br /> Qw <br /> S <br /> mt <br /> u,Vow- <br /> S <br /> IJ Oimanixw ay m <br /> CD �q�J <br /> N -) at. <br /> ' I 2 a N i2 . vv " <br /> aL <br /> ar aj <br /> r r � <br /> O <br /> a0' <br /> C k <br /> mi -�12�/ ISG aq .. �SC)a O• '�• o �- <br /> N� <br /> 06 F"42-04 <br /> 8/30/04 <br /> m <br />