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SAN JOAQUIN COUNTY <br /> < rM'1RONML'N"I-AL llm,uj DEPARTMENT Return this form by <br /> 600 Fast Main Street, Stockton,CA 95202-2708 the 12`h of each month <br /> \ % Telephone:(209)468-3420 Fns:(209)464-0138 HIM: yvww.sjgov.or ehd <br /> _ _ C r� SEPT'AGE CLEANER'S REPORT <br /> CL Company Name l��i�\�i � I!L;; �Utl ���v Report for the month of: k0- C.6 f3;.-F- year 2.61'6, <br /> Company Address: 7 c1 Cj ` �i ' \�\ct lcc is (c, ci Signature: <br /> Street Address— City "Lip Code <br /> All information submitted must be com lele, accurate, and legible <br /> (R) RFSIDF,'TIAL NAME OFTREATNIENT <br /> GALLONS <br /> DATF. NA�1E OFBUSINESS OR ADDRESS 1v1IIsI2E\vOR1C\YAS DONEGALLONScar-Asr:TRAe <br /> � PIIDIPED PROPERTY OWNER PUMPED FACILITY <br /> P I.FAST INCLUDE STREET N, DI It LCT 10 N, SI RF.EI' NA MP AND CITI' (C) CHEMICAL <br /> (D <br /> �p Cil' — <br /> CO -- — <br /> O <br /> C) — City <br /> City ---- — <br /> 1�v V�`.(��`• <br /> City Wil T - - <br /> _ city AR_ NV/No <br /> city _ NM <br /> City — <br /> 0 <br /> City <br /> — _ o <br /> z <br /> Clly _ <br /> n <br /> City _ m <br /> .— _— cwt <br /> Ci6 <br /> N <br /> SA�l,i VLA City o <br /> -- c� <br /> M <br /> > City o <br /> I <br /> t) City _ Y <br /> Q <br /> O City <br /> CD Cily <br /> CO — <br /> a� <br /> O Cily <br /> a� <br /> ■. ■ ■■�a Rt Septic/Cesspool Report <br />