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{ "IN v ucUINIV ,tv IAL,17L'f1L1111JLPAJt1MLN 1 Return this form by <br /> 600 East Main Street, Stockton, CA 95202-2708 the 121"of each month <br /> ' •�, P• Telephone:(209)468-3420 Fav:(209)464-0138 Web:www.sjgov.org/ehd <br /> �JFORay <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: ii ^^ Report for the io t of <br /> Company Address: t�O� ��� Signature: <br /> Street Address ) r, <br /> City Zip Code <br /> All information submitted must be com lete, accurate, and lc ible <br /> DATE NAME Or BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAL NAME OF TREATMENT <br /> PUNIPED PROPERTY OWNER PUMPED (G) GREASE TRAP FACILITY <br /> PLEASE INCLUDE STREET N, DIRECTION, STREET' NApiE AND CITY (C) CHEMICAL <br /> i r\ V City <br /> 1 r v Cit <br /> mooy <br /> Cit <br /> iv t <br /> Cit <br /> cit <br /> o� Ci <br /> -City <br /> of jol , <br /> Cit <br /> U ( City <br /> t City �iCiW <br /> Cit <br /> // City <br /> Cit <br /> ' City <br /> Cit <br /> City PP PAVED <br /> Cit <br /> City3 <br /> City ENVIRON ENTAL HEALTH <br /> Erm 42-04 <br /> Septic/Cesspool Report <br />