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SAN JOAQUIN PUBLIC HEALTH :;ERVICES <br /> SEPTIC TANK AND CESSPOOL CLEANERS REPORT <br /> 1 <br /> REPORTFt?R Tf-hE MONTH OF t,(,�' 19 IN SUB�SITTEO BY V-Zk' ADDRESS 737 Z4- ��"'�"'`'► � <br /> NAME OF ADDRESS WHERE GALLONS <br /> DATE PROPERTY OWNER WORK WAS DONE PUMPED WHERE CLEANINGS WERE UNLOADED <br /> Vail I J LI) <br /> ,L V <br /> cL'L ti t <br /> � d <br /> lid <br /> Q Q <br /> Return by the 12th of the month to I certify under penalty of perjury that the foregoing is true and cor <br /> San Joaquin Local Health District <br /> 1601 East Hazelton Avenue <br /> Stockton, CA 95205 DArT SKNATU <br /> RE OF APPLICANT <br /> EH 05 39 Rev. 5/82 <br />