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L11 <br /> v r till MJ11L 111 LC,YH1CI MtSIN 1 Return this corm by <br /> 600 East Main Street, Stockton,CA 95202-2708 the 12t"of each month <br /> W1�6 <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> SEPTAGE�CLEANER'S REPORT <br /> Company Name: (�+, } " �' Rep for the onth o <br /> �- �. <br /> Company Address: �� , � Signa <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 NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED (G) GREASE TRAP FACILITY <br /> PLEASE INCLUDE STREET 0, DIRECTION, STREET NAME AND CITY (C) CHEMICAL <br /> LAI Ci <br /> cit <br /> City <br /> C E <br /> Cit <br /> � <br /> Ci 4 <br /> NVIRONME -rAL H <br /> City r, <br /> CES <br /> city <br /> cit <br /> cit <br /> City <br /> cit <br /> Cit <br /> city <br /> cit <br /> cit <br /> City <br /> Cit), <br /> Cit• <br /> Cit <br /> Cit <br /> EHD 42-04 <br /> Septic/Cesspool Report <br />