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I N r uwtvtvll tv 1 tu,11Lt1L 111 1JGt'Hl�1 vir 1V I IKeturn this Torm by <br /> y' 600 East Main Street, Stockton, CA 95202-2708 <br /> the 12`i'of each month <br /> c, P• Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> ��FoRa; <br /> SEPTAGE CLEAN R'S REPORT <br /> Company Name: _ Report for the mo th ? yea <br /> Company Address: - L Signature <br /> Street Address 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) USIDENTIAL NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED (G) GREASETRAP FACILITY <br /> PLEASE IN UDE S REST N, 1) RECTION, STREET NA E AND CITY (C) CHEM1tICAL <br /> 5�t <br /> 1 <br /> City <br /> f City <br /> City <br /> City <br /> Cit <br /> City <br /> City <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> Cit <br /> City <br /> EHD 42-04 <br /> Septic/Cesspool Report <br />