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SAN JOAQUIN PUBLIC HEALTH JERVICES <br /> SEPTIC TANK AND CESSPOOL CLEANERS REPORT <br /> 19 r SUB��ITTEO BY �L ADDRESS �� <br /> REPQRT Ff}R THE MONTH OF S � � -���-- <br /> NAME OF ADDRESS WHERE GALLONS <br /> DATE PROPERTY OWNER WORK WAS DONE PUMPED WHERE CLEANINGS WERE UNLOADED <br /> -CL WE 57-bo <br /> of <br /> r <br /> &0 <br /> ° 1�;i <br /> f ate u n -rr c �-12-77L) c(� 5 <br /> :' (on5 2 3 Y" <br /> 6i-• kLL.1C <br /> rlCl ` <br /> LqQch !- e-, Fn V-L7ottrrJ51 a <br /> u <br /> ecu, _ v <br /> R(Yle-C jE X1U t <br /> Return by the 12th of the month to I certify under penalty of perjury that the foregoin is true and cor. <br /> San Joaquin Local Health District _ <br /> 1601 East Hazelton AvenueOAU <br /> Stockton, CA 95205 —DATE—� <br /> EH 05 39 Rev. 5182 _ <br />