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?, ENVIRONMENTAL HEALTH DEPARTMENT Return this form by <br /> 600 East Main Street, Stockton,CA 95202-2708 the 12"of each month <br /> a p Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.oreehd <br /> CrFo � <br /> ^1 J SEPT GE CLEANER'S REPORT <br /> Company Name: l Y IC�k( l5 yl (�' Report for m th o yeao�a <br /> Company Address: Signatu r <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 OF TREATMENT <br /> PUMPED PROPERTYOWNER PUMPED (G) GREASETRAP FACILITY <br /> PLEASE INCLUDE STREET M, DIRECTION, STREET NAME AND CITY C) CHEMICAL <br /> Ila <br /> J CC cid D 1 <br /> l , City <br /> City <br /> City <br /> City <br /> Ci <br /> Cit <br /> City <br /> Cit <br /> City <br /> City <br /> Cite <br /> Cir <br /> ON <br /> Ciry <br /> Cil <br /> Ci <br /> ON <br /> Cit <br /> EHD 42-04 <br /> SeptiUCesspool Report <br />