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-� un v IAVINIVIE N I AL,rftAL I H ILEPARTMENT Return this form by <br /> K 600 East Main Street, Stockton,CA 95202-2708 the 12'h of each month <br /> P Telephone:(209)468-3420 Far:(209)464-0138 Web:www.sjgov.org/ehd <br /> F <br /> • <br /> Company Name: SEPTAGE CLEANER'S REPORT !� <br /> L Report for the m o yeal( 1 <br /> Company Address: <br /> Street Address Slguatur - <br /> CiIY Zip Code -All information submitted must be co m tete, accurate, and le ible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE (R) RESIDENTIAL PUMPED PROPERTY OWNER GALLONS NAME OF TREATMENT <br /> PLEAS INCLUDE STREET a, DIRECTION, STREET NAME AND CITY PUMPED (G) GREASETRAP FACILITY <br /> (C) CHEMICAL <br /> City I 2 <br /> 7 Z Cit o V <br /> t rifv , -� <br /> z G <br /> city <br /> a3 0 l �Pa ! / {lG Ci <br /> l e) Ci <br /> Cit <br /> C' <br /> .d S <br /> WWI <br /> 7 a sig G Cuyc, 2L <br /> a� <br /> P-n'znlilL' pecd. Ci Naj- IIV \ <br /> 7 rG C; <br /> � 1 C <br /> Cit <br /> Cit <br /> Ci <br /> Cil <br /> Cit <br /> EHD 42-04 <br /> Septic/Cesspool Report <br />