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i,tq Y 11kUNI"Il N I-U,17=111,I t-I'JILV alt f MLN I Return this form by <br /> 600 East Main Street, Stockton,CA 95202-2708 the 121"of each month <br /> c P Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.ol'g/ehd <br /> �rFda�� <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: Repor onth of: yeah-!v�� <br /> Company Address: 4 Signa <br /> Street Address I City Zip Code <br /> All information submitted must be com lete, accurate, and legible <br /> DATE NAME Or BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAL NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED (G) GREASE TRAP FACILITY <br /> PY <br /> PLEASE INCLUDE STREET N, DIRECTION, STREET NAME AND CITY (C) CnEMICAL <br /> Cit <br /> rarl Cit <br /> City <br /> Cit <br /> Cit <br /> Ci <br /> City <br /> Cit <br /> Cit <br /> City <br /> City <br /> Cit <br /> City <br /> Cit <br /> City <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Clly <br /> EHD,t2-04 <br /> """' Septic/Cesspool Report <br />