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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT RECEIVE Return this form by <br /> 600 East Main Street, Stockton,CA 95202-2708 the 12th of each In <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd JUL Q $ Z 11 <br /> • (''. 'Q.•' y <br /> .q�rFaRTj� 1` <br /> L �i SEPIA` C EANERIS REPORT <br /> q�t111RONM AL STH <br /> Company Name: Report for thj ti yea <br /> Company Address: � Signat'ure: <br /> Street Address City Zip Code t <br /> All information submitted must be com tete, accurate, and legible <br /> DATE NAME OF BUSINESS OR ? ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAL TREATMENT' <br /> TRE <br /> PUMPED PROPERTY OWNER PIMPED (G) GREASE TRAP NAME OF OFTREFACILITY <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY (C) CHEMICAL <br /> Cit —OD /L <br /> cit <br /> city__ <br /> i <br /> o <br /> city Ac 5�0L-7z�wvl <br /> City <br /> Ci <br /> zc <br /> � > ���� �i�"'r/�S�'--•sa � Cit �/ ��C�� �' � - . <br /> Cit G <br /> A, <br /> -77L }�l <br /> ci `7ir <br /> cit <br /> City <br /> / J �r "� city / � <br /> D� 1 -711 <br /> +3 <br /> ZA2k [�'� I <br /> .rte ' ' Cit� <br /> Ci <br /> City r. <br /> EHD 42-Q4 ig i 1 <br /> — Septic/Cesspool Report <br /> 1 <br /> Y , <br />