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6U0 Last Main Street, Stockton,CA 95202-2708 the�2t1'of each mont,>t <br /> of c--- o <br /> IT Telephone:(209)468-3420 Fnt:(209)464-0138 �•�eG:wwwsjgov.org/ehd <br /> SEPTAGE CLEANER'S REPORT[' <br /> Company Name: l �l l <br /> y Repot t F the Uo4;hoI eaJ I <br /> Company Address: 1 c `i y <br /> ` I <br /> Street Address City Zip Code Signature: <br /> All information submitted must be com Ietc, accurate, and Ic iUle <br /> DATE NAME OF BUSINESS OR <br /> PUNIPED PROPERTY OWNER ADDRESS WHERE WORK WAS DONT; GALLONS (R) RESIDIs'NTIAL NAME Or TREATMENT <br /> PLEASE INCLUDE STREET M, DIRECTION, STRL•'ET NAME AND CITY PUMPED (0) GREASETRAP FACILITY <br /> (C) CnEhI1CAL <br /> Cit <br /> City <br /> � � � Gz ,tiCit •'� � � �� <br /> � Cit <br /> Cit• �j � � . <br /> t z <br /> Cine <br /> C J city <br /> Cit n <br /> `•'t <br /> � City � J �� <br /> Lu �i <br /> City � <br /> rsl CCit ✓f l/r C )w C <br /> City I U <br /> Cit <br /> �� Cit. <br /> j 1 - Cit 1 <br /> City. <br /> L•HD,12-04 <br /> - Septic/Cesspool Report <br />