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w,;6 <br /> IVIVIL'1V1r1LI KLM ijrrj l,IWitJ141 xeturn this cormby <br /> 600 East Main Street, Stockton,CA 95202-2708 the 12th of each month <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> t SEPTAGE C R'S REPORT <br /> Company Name: fyTA <br /> Reportf r t e nth of• year <br /> Company Address: � / �� Signature: <br /> Street Address Ciry Zip Code <br /> All information submitted must be complete, accurate, and legible ' <br /> DATE NAME Or BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAL NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED (r') GREASE TRAP FACILITY <br /> PLEASE INCLUDE STREET k, DIRECTION STREET NAME AND CITY (C) CHEMICAL <br /> City fz <br /> Ci <br /> ty <br /> Inoo(� —) City O( <br /> n, <br /> Cit <br /> city <br /> kEL ' Ci <br /> city <br /> �G6. cit <br /> D� <br /> 7 1-G L Ci n <br /> WTP <br /> -7-1 city <br /> (,)Tp 1 1J city <br /> /C� <br /> 1Q Cit `mss <br /> laks <br /> -s ty <br /> j�1 �1^ p� ci <br /> City <br /> Cit <br /> City <br /> City <br /> Cit <br /> EHD 42-04 <br /> Septic/Cesspool Report <br />