Laserfiche WebLink
a ENVIRONMENTAL HEALTH DEPARTMENT Return this form by <br /> w j 600 East Main Street, Stockton,CA 95202-2708 <br /> th <br /> • P • Telephone:(209)468-3420 Fox.(209)464-0138 Web:www.sjgov.org/ehd the 12of each month <br /> �rFORa� <br /> SEPT GE CLE NER'S REPORT <br /> Company Name: <br /> `1 l� Report for ttM month of• yearC2 <br /> Company Address: Signature• <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 4, DIRECTION, STREET NAME AND CITY ++' \ (C) CHEMICAL <br /> jszo <br /> " / 3 1 NK C Ci <br /> city <br /> cit <br /> Cit 1 r� <br /> ok cit, <br /> C) ilei S V city lDO <br /> ►� Cit l C51 <br /> Ci <br /> I (2- <br /> 53 L City OX <br /> ►� <br /> City <br /> Cit <br /> City <br /> City <br /> City <br /> Citv <br /> Ciry <br /> Cit <br /> EI-ID 42-04 <br /> ---• Septic/Cesspool Report <br />