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hNVIRONMENTAL HEALTH DEPARTMENT ��yy �� Return this form by <br /> a 600 East Main Street, Stockton,CA 95202-2708 (V= V the 12th of each month <br /> P Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.o ew�'` / <br /> SEPTAGE CLEANER'S REPORTIm w 13 2012 <br /> Company Name: Repo I a <br /> �qX yea <br /> Company Address. l Signatutrne�� <`'= <br /> Street Address city Zip Code <br /> All information submitted must be coIn tete, accurate, and legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAL NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED (G) caeASE TRAP FACILITY <br /> PLEASE INCLUDE STREET a, DIRECTION, STREET NAME AND CITY GREASET <br /> MICAL <br /> lid- (p") O.o.0 rr, Q ci S 1 C Kf ern ClOC7 Slee l� <br /> 3�3 alakern rOd ><ru 99 City �lx�`l�en re- 5 1�rfe� <br /> TDI a mryy— city 5bc \ier\ 2 r� <br /> 31� a <br /> Ar ( P., city ✓� <br /> 2 e -ri c; <br /> 3�8�ia �n}f �, FlU ` Jpt�e>rl <br /> Cil <br /> 3 9 i a L2J rn cx� , tlw % 2 <br /> 31�a1 �a <br /> /1�� � t�^l�J�-LLjJy-,�,� Ci r� ^�N <br /> urn vnb I�Ga� L[}rY�S'l..0 7 &-d city LA f) eI 1 �Yl�✓� <br /> ;&) t z� Rwj city)Is <br /> I)�'lia Di ►eos vv% city <br /> �� la 3asLt er a two <br /> 3 ) s , <br /> Much lane- Cuy 3sbo Slex�}e�rl <br /> r W o 35r'-'�-tU Ci C <br /> cit -ILCOC <br /> EID 42-04 <br /> Septic/cesspwi Report <br />