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W,;a <br /> "'Ivu"vtvlvil.lvrttLIMKI,Irikirt'lukIMt;N1 Return tris corm ny <br /> 600 East Main Street, Stockton,CA 95202-2708 the 12th of each month <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> SEPTAGE CLEANER'S RE ORT <br /> Company Name: Re <br /> =o�r 4theonth o yea Lf <br /> Company Address: <br /> Street Address Sig <br /> City Zip Code <br /> All information submitted must be complete, accurate, and legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAL <br /> PUMPED PROPERTY OWNER PUMPED (G) GREASE TRAP NAME OF TREATMENT <br /> FACILITY <br /> PLEASE INCLUDE STREET DIRECTION, STREET NAME AND CITY (C) CHEMICAL <br /> ic) City <br /> iU oG h� f ' <br /> jL <br /> Cit <br /> 1z d <br /> Cit Ci ► o coo <br /> 13L �//� � ,/� <br /> 1 1 ' CrV l ) <br /> 3Licim k • - I c1 city <br /> ) �•� l � ) Q cit <br /> U© /V . Ht / city <br /> j _ lb • <br /> City_ �} <br /> o�J , Cit <br /> Ci ca <br /> City <br /> / / Cit <br /> Ci <br /> (� 3 Ci <br /> LJ, , 0 �(� �O(.cel' �C. '&l• Cit <br /> City � <br /> /S G <br /> UU <br /> Cit <br /> EHD_ 42-04 <br /> `-"' Septic/Cesspool Report <br />