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{ LNVIRONMENTAL HEALTH DEPARTMENT <br /> Return this form by <br /> 600 East Main Street, Stockton, CA 95202-2708 the 12t1i of each month <br /> c, P Telephone: (209)468-3420 Fax:(209)464-0138 Web: ,vww.sjgov.org/ehd <br /> �rd'oRa� <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: k-L��ti 1 <br /> ' / �i� ' Report onth a yeaE�Y <br /> Company Address: l(�a�,� �. -�(nSignat <br /> Street Address City Zip Code <br /> All information Submitted must be con' tete, accurate, and-legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAL NAME OF TREATMENT <br /> MPED <br /> PUPROPERTY OWNER PUMPED (G) GREASE TRAP FACILITY <br /> PLEASE INCLUDE STREET N, DIRECTION, STREET NAME AND CITY (C) CHEMICAL <br /> 33 ,� <br /> City <br /> ►tel c> . q9 <br /> C City 1 X 1i C. <br /> I �e� na1 3S� zzG✓� Cit Ce�� 000 e- SC <br /> �))� 1 .CR Ci <br /> 13 'n alp <br /> Ci '2 <br /> ►� t is qct Cit V-4eo 12 <br /> 1 �LI uhf a I1 C' za City � <br /> t <br /> 53��� k L�Z7�Ln0 CittiU <br /> 3 i O(`i 4- Alt" City no 1 <br /> 39 13 3 ! 1 ,122ftd -PCit IN\/1 �2 <br /> ` moi► <br /> 20C) <br /> �' x CityC� 647 <br /> � 6 � -� �. ►� ic�c� 67 <br /> She�4pn City raoc> <br /> U (t �r'� City W <br /> i0( tooat <br /> cit <br /> city <br /> ERD 42-04 <br /> -"'""- Septic/Cesspool Report <br />