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�_ ={ ENVIRONMENTAL HEALTH DEPARTMENT Return this form by <br /> 600 East Main Street, Stockton,CA 95202-2708 the 12`h of each month <br /> Telephone: (209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> 4<< .6R R <br /> SEPTAE CLIA ER'S PORT <br /> Company Name: Repo oath of yeaz <br /> Company Address: ; Signatu <br /> Street Address City Zip Code <br /> All information submitted must be Com tete, accurate, and legible <br /> DATE NAME OF BUSINESS OR (R) RESIDENTIAL <br /> AL 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 /> ^yam i 1 Cit <br /> kk <br /> yb <br /> -xC <br /> rte` Ci aIJV <br /> / I V City -7 SLO c` <br /> ` Ci <br /> -I C�I ► e Cit -' k <br /> 3 <br /> City G <br /> Cityl C� <br /> Ci <br /> i Cit 1 <br /> SII : h o <br /> 1 Cit <br /> _ Cit qoo <br /> Cityr1^ tALJI��- i��al1 <br /> 1 1LlY �U� lrn Cit <br /> Cit <br /> Cit <br /> APR G' 2013 City -F <br /> Elm 42-04NV990N EPa 9:.L <br /> HEALTH Septic/Cesspool Report <br />