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ENVIRONMENTAL HEALTH DEPARTMENT Return this form by <br /> 600 East Main Street, Stockton,CA 95202-2708 the 12th of each month <br /> a r &e.- -3420 Fax:(209)464-0138 Web:www.sjgov.org/ebdAL NER' REPORT <br /> Company Name: - Report for the h a�ri 'Company Address Signature: <br /> Street AddressCity Zip Code <br /> All information submitted must be com lete, 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) GREASETRAP FACILITY <br /> PLEASE INCLUDE STREET R, DIRECTI N, STREET NAME AND CITY C CHEMICAL <br /> Ci .1 xcl <br /> J <br /> city <br /> �, e4 - / _� <br /> Ci L) t <br /> Coy <br /> CityS � cs OTJ J <br /> z- <br /> City <br /> Cit <br /> City <br /> City <br /> City <br /> City <br /> City <br /> Ci <br /> Ci <br /> r <br /> Ci <br /> Cil <br /> Ci <br /> Ci <br /> Cit <br /> Efm 42-04 <br /> "'-- Septic/Cesspool Repon <br />