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600 East Main Street, Stockton,CA 95202-2708 the 12t1i of each month <br /> Telephone:(209)468-3420 F& (209)464-0138 Web:www.sjgov.org/elid <br /> SEPTAGt CLEAN t R'S REPORT <br /> Company Name: �� _ �,.' 1 nn r <br /> ' r I Report p for the/oath of: <br /> Company Address: 0 t '�/) Signature: - <br /> Street Address City Zip Code Q <br /> All information submitted mast be Complete, accurate, and legible JAN ®9 2015 <br /> DATE NAME Or BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDFNTIAL IENT <br /> PUMPED PROPERTY OWNER PUMPED (G) GREASETRAP <br /> �� <br /> cc PLEASE INCLUDE S'rItEET N, DIRECTION, STREET NAM1fE AND CITY (C)/C'[IEMICAL P <br /> �� Cit <br /> ' elf _fiCity 5fr 0lrl <br /> ' City (� <br /> f � cit <br /> C ' nc CityL11azc <br /> 31c f ' /�Glr� 'Cc Ci )C 6L) S �� <br /> City <br /> i� sfcit <br /> MD 5f i <br /> City , <br /> Cit 5 <br /> Cit Sf <br /> i <br /> City <br /> hL <br /> dCit <br /> City, j <br /> Cit <br /> 1. <br /> cit <br /> 5v 4 / , Cit <br /> EFQ)42-04 Septic/Cesspool Report <br />