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600 East Main Street, Stockton, CA 95202-2708 the 12`I'of each month <br /> F <br /> �• P <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web:tvww.sjgov.org/ehd <br /> ��FO Ra <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: t <br /> - �YV\ • Report for tl> in u h <br /> Company Address: �S Signature: C <br /> Street Address City Zip Code <br /> All information submitted must be com Ictc, ;t—Irate, and legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAL NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED (G) CREASE TRAP FACILITY <br /> CcPLEASE INCLUDE STREET 11, DIRECTION, STREET NAME AND CITY (C) CREMICAL <br /> al <br /> I Cit <br /> City <br /> 1 Cit <br /> LE,l2 <br /> Cit, .( <br /> cit <br /> cit <br /> �- <br /> City <br /> Cit: %tel <br /> l�w l city ' <br /> \ - )I)rjC Cit � <br /> Cit <br /> city <br /> ' ll <br /> • city) <br /> •l E J &-0 city <br /> 'til" 'Yb IL(cit <br /> ( �1• Cil <br /> FIT,t-2-o4 <br /> - -• Septic/Ccsspool Report <br />