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600 East Main Street, Stockton,CA 95202-2708 the 12t1'of each month <br /> P Telephone:(209)468-3420 Fxv. (209)464-0138 Web:www.sjgov.org/ehd <br /> I SEPTAGE CLEANER'S REPORT <br /> �'M , � � '✓ Reporta mo h of: year. <br /> HEALiti <br /> Signature: <br /> PERMIT/SERVICES Street Address City Zip Code <br /> All information submitted must be eom lete, accurate, and legible <br /> DATE NAME Or BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAL NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED (G) GREASE TRAP OF TR A <br /> PLEASE INCLUDE STREET tl, DIRECTION, STREET NAME AND CITY (C) CHEMICAL <br /> TY <br /> Cit <br /> City Tr-bau Tr-bP, (l J <br /> - <br /> 12 <br /> C/�� Cit <br /> 1pc1 cit <br /> I Cit <br /> 2 <br /> C<--- <br /> � <br /> i i city 1 ly 1� <br /> r city <br /> 11 >, QLD cityP TCI ' <br /> It cit } <br /> G` <br /> 1 ? <br /> GC� cit <br /> P'N I C t S t, 1. <br /> Cit <br /> Cit <br /> ` � <br /> 0-[La-) �� <br /> I� c <br /> r <br /> Cilv <br /> EHD,12-O4 <br /> Septic/Cesspool Report <br />