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LNVIRONMENTAL HEALTH DEPARTMENT Return this form by <br /> 600 East Main Street, Stockton, CA 95202-2708 <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd the 12`l'of each month <br /> MA SEPTAGE CLEANER'S REPORT <br /> 14,r <br /> w '­- pany Name: t,K` <br /> 1 � rryG ��ti� V1C i Report fonth of: ear` <br /> dress. �S Signature <br /> Street Address City Zip Code <br /> All 1r.,' submitted must be complete, accurate, and legible <br /> R%�A NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAL NAME OF TREATMENT <br /> MPED PROPERTY OWNER PUMPED (G) GREASE TRAP FACILITY <br /> ` 1 PLEASE INCLUDE STREET N, DIRECTION, STREET NAME AND CITY (C) CHEMICAL <br /> 1 Citv r �Q n <br /> ���I1I i11;1 i c� Q <br /> Cit <br /> City I <br /> y ' Li�t C. <br /> Cit ? 1� <br /> f� 1 (-'ok Cit <br /> a � city . h' _ <br /> -+_,n . �L La k' Pcr-J Cit <br /> 72l CityCity LVyLv\ <br /> RIC ,; " i 13 L e I;CCit c � kocc` <br /> /7 f SC h P� ( h ` \g Cit � / 1 <br /> �� lC �. L.lv�►A • �.-�-� cit <br /> C) , <br /> rcz,'�rl C�� �. <br /> city <br /> r / �•3 VYL� -l.{S �l_� Cit -+�.SZ-�` II`-',� t , <br /> Y r 1 , �{`cit <br /> City <br /> 9kd <br /> Cit <br /> 7(, <br /> Cit, <br /> ERD 42-04 <br /> Septic/Cesspool Report <br />