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600 East Main Street, Stockton,CA 95202-2708 the 121h of each month i <br /> CC <br /> wla 'z; Telephone.(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: <br /> Report for the o th of: yea <br /> Company Address: ` r� <br /> Signature: <br /> Street Address <br /> Ci <br /> Zip Code <br /> All information submitted must be complete, 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 FACILITY <br /> PLEASE INCLUDE STREET 11, DIRECTION, STREET NAME AND CITY (C) CHEMICAL <br /> Cit <br /> 47, Cit G <br /> City (y <br /> S cit —D <br /> C• <br /> Cit /t <br /> Ci7775 0 <br /> O D /J G� cit 60 De <br /> 2/373 /\JC Kos cit '7�6G d <br /> ^ City <br /> r cit <br /> �L LAG' j Cit C <br /> cit <br /> alU . 9 cit <br /> Cit <br /> Cit <br /> Cit <br /> cit <br /> Cit <br /> Cil <br /> EHD 42-04 <br /> ---• Sep6clCesspool Report <br />