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SAN JOAQUIN PUBLIC HEALTH JERVICES <br /> SEPTIC TANK AND CESSP OL CLEANERS REPORT <br /> REPORT F&r VHf MONTH OF 19 SUBMITTED BY 1A6& ADDRESS 3 7z� �� u <br /> NAME OF ADDRESS WHERE GALLONS <br /> DATE PROPERTY OWNER WORK WAS DONE PUMPED WHERE CLEANINGS WERE UNLOADED <br /> UC lco <br /> sic c l1 Co <br /> �,^.Lti.�-d'► "�l '�:' _tet L���' <br /> fill <br /> � � C 1 CUc rev <br /> p <br /> Return by the 12th of the month to I certify under penalty of perjury that the foregoing is true and corn <br /> San Joaquin Local Health District <br /> 1601 East Hazelton Avenue <br /> Stockton, CA 95205 UATE SIGItATZRE OF APPLICANT— <br /> EH 05 39 Rev. 5/82 . <br />