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{ ENVIRONMENTAL HEALTH DEPARTMENT Return this form by <br /> 600 East Main Street, Stockton,CA 95202-2708 the 12t4 of each month <br /> a P • Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> R <br /> a` <br /> SEPTAGE CLEANER51 REPORT <br /> Company Name: A 11t> 1. (� ,, I n� e th <br /> l7� mon o€• year �. )lam <br /> Company Address: A, lo q Sa Sign <br /> Street Address City Zip Code <br /> All information submitted must be complete, accurate, and legible .,,, mow '• <br /> DATE NAME OF BUSINESS OR (R) RESIDENTIAL( <br /> ADDRESS WHERE WORK WAS DONE GALLONS - h F TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED G) GREASE TRAP Y <br /> il <br /> PLEASE INCLUDE STREET H, DIRECTION, STREET NA11fE AND CITY (C) CHEMICAL <br /> � 3l ►2 , <br /> i3 u� (ii re.. 3Z� Ch2� <br /> City <br /> City <br /> city WV <br /> /�/��\ <br /> `� 13 (1 (Gid �I h►� <br /> ` LVI1e�' rnt+. GI tot 1� city inc- t� 01JOV <br /> n 3sI;iwn _azo C <br /> 1 w .Oou Y1�ry ClUb city <br /> Cit I lJ J l <br /> e • - Ci ppo <br /> VCS City C-7 <br /> '� ► �- rn t l , alo Ci <br /> ty <br /> as�-o �zz�tno C �r� o <br /> 1 /�` C <br /> � l cit 1� <br /> II 13 LA q Cit n 9�0 <br /> 13 I e Q�p <br /> Cit 7sw <br /> 'rcQ 5� s• ow I, <br /> N rranino eO,hQ, Ci (aoo P-- <br /> I In der' <br /> Cit <br /> EHD 42.04 <br /> "' - Septic/Cesspool Report <br />