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RECEIVEt) <br /> CD w <br /> 'n�� SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by the <br /> wMMAO �E� iALFK-- 1868 East Hazelton Avenue, Stockton, CA 95205-6232P11sw1 'if�r�i�E% Telephone: (209)468-3420 Fax: (209)464-0938 Web:wwW.sjgov.orglehd12th of each month <br /> SEPTAGE CLEANEF°:5 REPORT <br /> Company Name: pr a g ,r3 <br /> / C Report for the mon of: Y. year <br /> Company Address: i20/ /Qosco-f Signature: �c <br /> Stteel Address CAy Zip Code <br /> All information submitted must be CDn3 late, accurate, and legible <br /> DATE NAME OF BUSINESS OR <br /> PUMPED PROPERTY OWNER ADDRESS WHERE WORK WAS DONE GALLONS (R) GREAENTSE P-k NAME OF TREATMEPIT <br /> CJ PLEASE INCLUDE STREET A, DIRECTION, STREET NAME AND CITY PUMPED {G) CHEMICAL <br /> HE ICAL a FACILITY <br /> Z {C) CH�d11CAL <br /> H C4'»r <br /> c. <br /> 9� <br /> 1719?4AC4%wI es <br /> iFd t, Ci <br /> oily i. <br /> a OrZ �f4 Li at%C cn T^qa 07,00V /e. rq t <br /> Ci svrD ti <br /> i l oOcK �•-s .�y� .�i1� • c��ltt - it'J,fGv C ,�Q4'"9 tea o c I ` 4 <br /> � clly <br /> f.�,c.`. •, <br /> vc/ o.2' rL ♦o - <br /> N zs, <br /> 00 <br /> o <br /> CD Cil <br /> d- <br /> LO <br /> Q, cif <br /> m T <br /> cv o <br /> CO a <br /> CD <br /> cny o <br /> Lo c t <br /> m � <br /> � ca <br /> Lo Page D( <br /> CD <br /> EHD 42-04 <br /> 1 Zf27?1J <br /> SEPTAGE CLEANERS REPORT <br /> ■ <br /> .�■ ■.titi■ <br />