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hNVIRONMENTAL HEALTH DEPARTMENT r1`VCI Y CU Return this form by <br /> 600 East Main Street, Stockton, CA 95202-2708 the 12th of each month <br /> �, P • Telephone:(209)468-3420 Fx (209)464-0138 Web:www.sjgov.ordiGcV 0 6 2014 <br /> �1FORa <br /> SEPTAGE CLEANER'S REPORT 9 <br /> ENVIRONMENTAL HEALT <br /> Com an Name: RepoWFNl� ;@4of: <br /> � Yeat�� � <br /> Ll <br /> Company Address: l �, / Signature: pn <br /> Street Address City Zip Code <br /> Al information submitted must be coni plete, accurate, and legible <br /> NAIVE OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R� RESIDENTIAL NAME OF TREATMENT <br /> LDATE <br /> U)viPED PROPERTY OWNER PUMPED (G) GREASE TRAP FACILITY <br /> PLEASEINCLUDE STREET N, DIRECTION, STREET NAME AND CITY (C) CHEMICAL <br /> �..Jl. 7 City4,- <br /> i City <S+r. <br /> VMS 10 1CC City <br /> cit <br /> 1 + ' cit ' <br /> 2S City <br /> City rlJ�/�/ C, ti <br /> t � <br /> r rc Mrd pit E <br /> kc, )_ LL c l city t CCU <br /> A City <br /> l I J 1 Cit t C 1 <br /> Cityla� � <br /> C1C1 City <br /> It3 fJ — 1 I✓ ivQj <br /> Y� <br /> City <br /> cit <br /> Cit <br /> �I, .�� � c;t <br /> 1� �u Cly c i r k <br /> IU cit <br /> City <br /> Exo 42-04 <br /> --•---- Septic/Cesspool Report <br />