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hNV1RONMENTAL HEALTH DEPARTMENT Return this form by <br /> 600 East Main Street, Stockton,CA 95202-2708 the 12th of each month <br /> 6 P • Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> FOR <br /> ^ SEPTAGE CLEANER'S REPORT <br /> Company Name: J! <br /> Reporta nth o yea <br /> Company Address: Signatu <br /> Street Address City Zip Code <br /> All information submitted must be complete, accurate, and legible <br /> EDMATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAL NAME OF TREATLU Lt <br /> MENT <br /> PED PROPERTY OWNER PUMPED (G) GREASE TRAP FACILITY <br /> PLEASE INCLUDE STREET k, DIRECTION, STREET NAME AND CITY (C) CHEMICAL <br /> a cityIT/SERVICES <br /> 013 1 city <br /> City <br /> t Ci It�C 2 <br /> L ' e-0I v4cr Ci <br /> v, I=LL City ► 2 <br /> city � <br /> Cit S <br /> City <br /> s c P i 13 --q-3 <br /> city z CIC4 0— <br /> cit <br /> A02City 64 C—il <br /> , Cit VT k_ <br /> Cit ZZ� <br /> v. city <br /> ce � <br /> r /� Cit <br /> Cit �p�G T• <br /> U 1 Gled cit <br /> El D 42-04 <br /> Septic/Cesspool Report <br />