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w <br /> 600 East Main Street, Stockton, CA 95202-2708 the 1211i of each month <br /> Telej)hone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: r` ��1 �. ,�L <br /> • � �' Report for tl outlz #�� C year3cilt6 <br /> Company Address: <br /> Street Address Signature: <br /> City Zip Code <br /> All information submitted must be coni lete, accurate, and legible <br /> DATE NAME Or BUSINESS OR ADDRESS WHERE WORK WAS DONT; GALLONS (R) nESIIENTIAL NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PPUMPED (G) GREASE TRAP FACILITY <br /> LEASE 1NCLUUE STREET N, DIRECTION, STREET NAME AND CITY (C) CREMICAL <br /> City <br /> y <br /> city. (� <br /> �-.- <br /> � <br /> Ci!Y OT <br /> 1 l r Ci ` NZi <br /> Cit <br /> L. Cit <br /> � — Cil• � <br /> City <br /> 1 <br /> City <br /> Citv r — <br /> �fY Cit I {` <br /> Ci" <br /> ic- <br /> Cit <br /> Cit <br /> City <br /> city <br /> Etm.12-04 <br /> Septic/Cesspool Report <br />