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N.' : LNVIRONMENTAL HEALTH DEPARTMENT Return this form by <br /> 600 East Main Street, Stockton,CA 95202-2708 the 12th of each month <br /> c• P Telephone: (209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> <iFORa <br /> SEPTAG { CLEAN R'S REPORT <br /> Company Name: � ^1--�(JxS l� ' <br /> i� Re ort for the i o Veal/ <br /> Company Address: Cy Signature: <br /> Street Address City Zip Code <br /> All information Submitted must be complete, accurate, 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) GREASE TRAP FACILITY <br /> PLEASE INCLUDE STREET N, DIRECTION, STREET NAME AND CITY (C) CIIEAIICAI, <br /> AV Citv <br /> / Cit <br /> y S74 IZCJ <br /> City V V <br /> Cit <br /> City <br /> City <br /> City <br /> Cit <br /> City <br /> City <br /> Citv <br /> City <br /> cit <br /> City <br /> Citv <br /> City <br /> Cit <br /> Cit <br /> Cit <br /> City <br /> El-ID 42-04 <br /> ---• Septic/Cesspool Report <br />