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LNVIRONMENTAL HEALTH DEPARTMENT Return this form by <br /> `I 600 East Main Street, Stockton, CA 95202-2708 the 12th of each month <br /> r Telephone:(209)468-3420 Fret:(209)464-0138 Web:www.sjgov.org/ehd <br /> C". P <br /> <<PORa <br /> SEP AGKCLEAN R'S REPORT <br /> Company Name: C '� C year,may <br /> Report for th n h o . ' . ) <br /> C � <br /> Company Address: � , <br /> Signature: i <br /> Street Address City Zip Code <br /> All information submitted must be complete, accurate, and legible <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DONE GALLONS (R) RESIDENTIAL NAME Or TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED (G) GREASE TRAP FACILITY <br /> PLEASE INCLUDE STREET N, DIRECTION, STREET NAME AND CITY (C) CHEMICAL <br /> 1 City 4 <br /> cn <br /> . - �� n CityL I V cc) <br /> r/i I /�y ,\ hQ (��\�\ L�� � q city <br /> ��ll.l�.�J it1 f City , <br /> bo <br /> Uilt� m <br /> city <br /> City <br /> City , <br /> Cit <br /> City <br /> City <br /> Cit <br /> City <br /> City <br /> City <br /> City <br /> Cit <br /> Cit <br /> Cit <br /> City <br /> EIID 42-04 <br /> -.---- Septic/Cesspool Report <br />