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tNVIRONMENTAL HEALTH DEPARTMENTF7'.'ZCl <br /> 4@. Return this form by <br /> 600 East Main Street, Stockton,CA 95202-2708 the 12th of each month <br /> i IN 12 2013 Telephone:(209)468-3420 Fax:(209)464-0138 Web:Nvww.sjov.org/ehdj 2013 <br /> I ld <br /> SEPTAGE C"ANER'S REPORT wr <br /> ;�'of <br /> Company Name: C�-0 <br /> (� ) Rep or nth of. year(j-X6Z3 <br /> Company Address: 10 OJT Signature: on <br /> -e - <br /> Street Address City Zip Code <br /> All information submitted must be complete, accurate, and legible <br /> DATE NAME OF BUSMESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAL NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED (G) GREASE TRAP <br /> PLEASE INCLUDE STREET 0, DIRECTION, STREET NAME AND CITY (C) CHEMICAL FACILITY <br /> J13 <br /> 4 -7 Citv <br /> A City <br /> City <br /> Ci <br /> 35 Z Cit y 5qv'j <br /> S . CitySOo <br /> City 3ttla <br /> 0 �zql'x5l City _34)t'r) <br /> 13&6 1 Ll City iso <br /> City <br /> Citvs±96 R <br /> City0— <br /> - --- <br /> Cit v <br /> City�� <br /> 'A/ 99 City�� zk4 <br /> City <br /> /3 Citv <br /> /3 City <br /> 3 7 37 011e 7 city A2 <br /> Azz/ City <br /> EliD 42-04 <br /> Septic/Cesspool Report <br />