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ECEVEDaan jonclum f.nunty Vnvironu;enLat r"CH1K11 "IVISIon <br /> peptic Tank and Cesspool Cleaners Report h { L <br /> EN <br /> a MONTH OF:EL map <br /> - , 2-avo�J <br /> DATE NAME OF PROPERTY ADDRESS.WHERE WORK GALLONS WHERE CLEAKINGS WERE UNLOADED <br /> OWNER WAS COMPLETED PUMPED <br /> �;/o (C X <br /> LdY'$t 1�r1�j• <br /> y oaf t..x's <br /> Q <br /> a . <br /> a <br /> I <br /> r <br /> N <br /> 'cS <br /> R � <br /> N <br /> lf7 <br /> Cn <br /> m <br /> N i <br /> 11 <br /> V <br /> r-I <br /> Q1 <br /> N Return by the 12"of each month to I CERTIFY I JNDER PENALTY OF PE.YJURYAHAT TM FORGOING IS TRUE AND CORRECT, <br /> FAvlronmrnid Hulth Diviainn <br /> v 304 Cant Weber Avcaue,3d Finer <br /> Stockton,CA 95202 ATL SI NA OF APPLICANT / <br /> sepRrp Rev.12199 <br />