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Septic Tank and Cesspool Cleaners Report <br /> 5 d � <br /> COMPANY NAME: <br /> ,COMPANY ADDRESS: Oa;) EaLZ _ a TA - S <br /> REPORT FOR THE MONTH OF: ,2000 <br /> DATE NAME OF PROPERTY ADDRESS WHERE WORK GALLONS WH RE CLEANINGS WERE UNLOADED <br /> OWNER WAS COMPLETED PUMPED <br /> k <br /> b e 000 <br /> r <br /> • <br /> f <br /> Return by the 12"of each month to 6 I CERTIFY UNDER PENALTY OF P7JURY THAT THE F AGOING IS TRUE AND CORRECT. <br /> Environmental Health Division t <br /> i <br /> 304 East Weber Avenue,Sed Floor Z�� <br /> Stockton,CA 95202 DATE -SIGNATURE OF APP '!ICANT <br /> SepRep Rev.12199 <br />