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600 East Main Street, Stockton, CA 95202-2708 the 12t1'of each naontli< <br /> _ <br /> �;. Telephone:(209)468-3420 Fax:(209)464-0138 Web:«ww.sjgov.org/ehd <br /> 1 S EPTAGE CLI PORT <br /> B J <br /> Company Name: 1 �/ 'L+ <br /> 1 Deport for the i o t of: year U <br /> Company Address: c9 7 <br /> 5ignatui e: <br /> Street Address City Lip Code <br /> All information submitted must be Coll, Tete, accurate, and is ible <br /> DATE NAA-IE OG BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAL NAME OF TREATMENT <br /> I'U)VII'ED PROPERTY OWNER PUMPED (G) cREASETnnP IACILITY <br /> PLEASE INCLUDE STRL•'E-r V, DIRECTION, STRL•'ET NAME AND CITY (C) CIIEM1ilC,11. <br /> taC `-✓-� City <br /> City <br /> City <br /> City <br /> Cit <br /> Cit <br /> Cit <br /> Cil <br /> City <br /> City <br /> Citv <br /> Cit <br /> City <br /> Cil), <br /> City <br /> City <br /> City <br /> City <br /> City <br /> Citv <br /> EHD 42-04 <br /> ""' Septic/Cesspool Report <br />