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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 /> c, P • Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/chd <br /> q<,FaRa` <br /> SEPTAAECL NER'S REPORT <br /> Company Name: to n' t �'� <br /> Report forte 10 th o • yea Address: / -� <br /> Company Address: Signature 1 1� <br /> Street Address City Zip Code <br /> All information submitted must be complete, accurate, and legible <br /> DATE NAME OF BUSINESS OR (R) RESIDENTIAL <br /> ADDRESS WHERE WORK WAS DONE GALLONS NAME OF TREATMENT <br /> PUMPED PROPERTY OWNER PUMPED (G) GREASE TRAP FACILITY <br /> PLEASE INCLUDE STREET #, DIRECTION, STREET NAME AND CITY (C) CHEMICAL <br /> Ci <br /> - — — Cit <br /> City <br /> Cit <br /> vi ), Cit <br /> P� '11'1ow Q <br /> all <br /> Ci <br /> Ci <br /> Cit <br /> city )S <br /> City <br /> cit <br /> d ( IC Itm <br /> �� /� Ci rn <br /> Cit <br /> x D �-..,.,e city, <br /> City <br /> 10 pbad City <br /> 3 356(:� ccs Cit C <br /> I 3 1 <br /> Ci <br /> 1' <br /> City , <br /> EHD 42-04 <br /> -------- Septic/Cesspool Report <br />