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600 East Main Street, Stockton,CA 95202-2708 the 12t1i of each month <br /> �• P Telephone:(209)468-3420 Fccr:(209)464-0138 Web:www.sjgov.org/ehd <br /> � FORa, <br /> SEPTA t CLEAN +R'S REPORT // <br /> Company Name: J / Report for th year��I`7 <br /> lccCompany Address: Signature: �4 <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) RESIDENTLIL NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED (G) GREASE TRAP FACILITY <br /> `` PLEASE INCLUDE STREET N, DIRECTION, STREET NAME AND CITY (C) CHEMICAL <br /> I� <br /> City <br /> P1 OA— <br /> } Cit <br /> City kq� C—` <br /> Cit gxjnL J <br /> " T Cit <br /> W , tdnrjcity 'z� tn�l- <br /> A <br /> Cit• 7500 <br /> 1 � , <br /> Cil <br /> C° -Cno <br /> I Cil <br /> 1 Cit <br /> I <br /> &ChalCit•3n k Z�� At <br /> O/ �� Cil <br /> l/ll / I e Cil <br /> Cil <br /> Cit <br /> Cit <br /> Cit <br /> City <br /> EHD 42-04 <br /> " ' Septic/Cesspool Report <br />