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! SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form-by <br /> 500 East Main Street, Stockton,CA'95202-2708 k the 121h of each month <br /> .2Q�a T .qphone'(20S9): 468-3420 Fax:( 09)464-0138 Web:www.sjgov:orglehd <br /> - crKor{��P ' '� <br /> i I kiEA� EPTAGE C NER'S REPORTo a Rep6ort far the nth ` yeaC mp ny Name:Company Address: r signature: <br /> Street Address. City Zip Code II i <br /> All information submitted must be c0m lete, aceurate, and legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE ' GALLONS (R1smE NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED �G) GREASE TRAP FACILITY <br /> PLEASE INCLUDE STREET44h .7ak <br /> it, pIfiECTtON, STREET NAME AND CITY' (C) CI3EMTCAL <br /> 4 r <br /> City <br /> �n r city+ 4 'A <br /> D 11 - .Ci <br /> !! X44 S� �• <br /> QtPI / ci Q C. <br /> ! Ci <br /> city C' <br /> Scit t' Cd S - <br /> tr Q cit ate d <br /> Gt-,74 (anal jV'l idCit <br /> � <br /> snoc-le. <br /> cis fr 900 <br /> 754A r& <br /> — e ar ci <br /> 4 J KE INQ , ' Cik7n <br /> c;t <br /> ci 5we AAza r <br /> t <br />(1� � 119 b ct C- {�4l � �:•� `i <br /> cit G r" <br /> EHD 42-04 x t Septic/Cesspool Repoli <br />