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ENVIRONMENTAL HEALTH DEPARTMENT Return this form by <br /> 11�" <br /> 600 East Main Street, Stockton,CA 95202-2708the 12°i of each month <br /> Telephone:(209)468-3420 Fax.(209)464-0138 Web:www.sigov.org/ehd <br /> `PRS <br /> SEPT E CLE ER'S PORT <br /> Company Name: Cyl� Report for the nth of. yea(W— <br /> Company Address: / Signatur . <br /> Street Address City ip 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 OF TREATMENT <br /> PUMPED PROPERTY OWNERPUMPED (G) GREASETRAP FACILITY <br /> r� PLEASSEE IINCLLUUDE^S�TRREEETT p, DI ECTION, STREET NAME AND CITY (C) CHEMICAL <br /> IP JV &ZC1 wo )66ad <br /> a -;:T/D0 • '79 city <br /> a14p,�,'` Cit <br /> ^� _Sz 0 11 Ci <br /> l aP .l O i I/[/'C_ • city <br /> city <br /> city <br /> city <br /> City <br /> Ci <br /> at <br /> Cityp p 2012 <br /> city 1_TH <br /> Ci E V1 ERMITISERVICES <br /> City <br /> City <br /> at <br /> City <br /> Ci <br /> City <br /> can v,-ua <br /> Septic/Cesspool Repon <br />