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rNVIRONMENTAL HEALTH DEPARTMENT Return this form by <br /> 600 East Main Street, Stockton,CA 95202-2708 the 12"of each month <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> IWO <br /> SEPTAGE CLE NER'S REPORT <br /> Company Name: Report for the th of- ye� <br /> / <br /> Company Address: a )S Signature <br /> Street ddress City Zip Code <br /> All information submitted must be mrilete, 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) GREASE TRAP FACILITY <br /> PLEASE INCLUDE STREET R, DIRECTION, STREET NAME AND CITY (C) CHEMICAL <br /> a rn z <br /> City <br /> City <br /> V 1 c o1�LX5 <br /> a iCityS <br /> 3 PJ G <br /> A s Qd Cit <br /> City <br /> Cit <br /> City <br /> City <br /> City <br /> City <br /> City <br /> Ciry <br /> Citv <br /> Ciry <br /> rd <br /> EHD 42-04 <br /> Septic/Cesspool Report <br />