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J--,'N v 11\VIN1vIL"IN 1 K1.,17Ll1L 1 Pt 1JL1'AJ<1 ML~N l Return this form by <br /> 600 East Main Street, Stockton, CA 95202-2708 the 12t1i of each month <br /> �• a.. Telephone:(209)468-3420 Fxv:(209)464-0138 Web:www.sjgov.org/ehd <br /> �rFaR�� <br /> SEPTAGE CLEANER'S REPORT //�������� <br /> Company Name: Report forftieutft yeaicq�t <br /> Company Address:) Signature: <br /> Street Address City Zip Code <br /> All information submitted must be Complete, 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 /> PLEASEINCLUDE S'!'REET ll, DIRECTION, STREET' NAME AND CITY (C) C11ERIICAL <br /> "I J� Cit <br /> Cit <br /> City <br /> Cit <br /> Cit <br /> Cit <br /> City <br /> Cit <br /> City <br /> City <br /> City <br /> Cit <br /> Cit <br /> City <br /> City <br /> Cit <br /> Cil <br /> Cit <br /> LEE Cit <br /> City <br /> PHD 42-04 <br /> Septic/Cesspool Report <br />