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ENVIRONMENTAL HEALTH DEPARTMENT Return this form by <br /> 600 East Main Street, Stockton,CA 95202-2708 the 12 It of each month <br /> e P Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> SEPT GE CL/EANER'S REPORT <br /> Company Name: ( Report for th o th year <br /> Company Address: Signature — <br /> Street Address City Zip Cade <br /> All information submitted must be com fete, accurate, and legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAL NAME OF TREATMENT <br /> PUMPED PROPERTYOWNER PUMPED (G) eREAse TRAP FACILITY <br /> PLEASE INCLUDE STREET q, DIRECTION, STREET NAME AND CITY C) CHEMICAL <br /> 1 e <br /> CI <br /> ty <br /> City <br /> CII <br /> City <br /> City <br /> City <br /> City <br /> Cit <br /> City <br /> City <br /> City <br /> City <br /> City <br /> City <br /> Cit <br /> City <br /> City <br /> City <br /> City <br /> Cil <br /> EHD 42-04 <br /> ---- Septic/Cesspool Repon <br />