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600 Last Main Street, Stockton,CA 95202-2708 t-- ---12" of each month <br /> c ` <br /> P Telephone:(209)468-3420 Frit:(209)464-0138 Web:www.sjgov.org/ehd <br /> 0 <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: 1 � t� , <br /> L ' Report for outh of:, year <br /> Company Address: I <br /> y `ll Signature• <br /> Street Address City Zip Code <br /> All information submitted must be com Icte, accurate, and le iblc <br /> EIVE <br /> BATE NAME E BUSINESS OR ADDRESS'4' HERE WORK WAS DONT; (R) nESIDENTIAL <br /> PUMPED PROPERTY OWNER GALLONS NAME 6� iC ILCC�►ii <br /> PLEASE INCLUDE STREET 11, DIRECTION, STREET' <br /> NAME AND CITY PUMPED (G) GREASE C„VjI.ITY <br /> 3 (C) MEMICAL „V <br /> Cit dl� E Vic <br /> LA f K <br /> j A' cit <br /> Q�� J J' Vl city f r ► I/' <br /> C C cit <br /> LAI � <br /> 1 1 I Cit Q <br /> Cit <br /> Cit <br /> I yj �" City 2 <br /> — 1 + Cil J. , <br /> Citv c <br /> city 1 L <br /> cit <br /> Inde <br /> city <br /> ci, C I1�,0 <br /> Ow--7p 2d- <br /> City <br /> (� Cil -a I <br /> Cit <br /> Gl � <br /> EHD,12-04 <br /> — Septic/Cesspool Report <br />