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viv v 11'.u"AvAA:AN A rtl,1l iL 1 Cl LH <br /> CYKI MtN 1 Keturn tBiS corm by <br /> ` w,5 ; <br /> 600 East Main Street, Stockton,CA 95202-2708 the 12th of each month <br /> c. Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: tf 1( `l1'�• Report r'tfhemo th of: year rQG <br /> Company Address: CO ��l�,c�l 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 jNUE44REATMENT <br /> PUMPED PROPERTY OWNER PUMPED (G) GREASE TRAP FACILITY <br /> PLEASE INCLUDE STREET 4, DIRECTION, STREET NAME AND CITY (C) CHEMICAL <br /> _1InLL - city PE <br /> - - <br /> • ' ow <br /> Ci <br /> cit <br /> N <br /> Ci <br /> I— — city <br /> 1I-I1-f3 (�:�Lke�Dy) City � <br /> t alic- <br /> Cit <br /> Ci <br /> ty <br /> city <br /> Cin <br /> C.Jon, Ci —� I 0 1� <br /> — -LEL Cit yl- <br /> CityS)-LH <br /> o S <br /> ci 3 GO e- <br /> I►�I c/�t� V 1 A Ci - OG <br /> C., <br /> 11-1�s- 3v o `J I C� I'Z <br /> Ci <br /> Ci <br /> 1- � 1 � citC~�JI r•'� I 'O � �TI 1 <br /> EFID 42-04 <br /> — -• Septic/Cesspool Report <br />