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SAN JOAQUIN PUBLIC HEALTH JERVICE5 ' <br /> SEPTIC TANK AND CESSPOOL CLEANERS REPORT <br /> 01 <br /> REPORT FE* T* MONTH OF_ Is" /19 SUBMITTED BY E ADDRESS 72-� � <br /> r/L <br /> NAME OF ADDRESS WHERE GALLONS <br /> DATE PROPERTY OWNER WORK WAS DONE PUMPED WHERE CLEANINGS WERE UNLOADED <br /> Return by the 12th of the month to I certify under penalty of perjury thatthe 'foregoing is true and cor- <br /> San Joaquin Local Health District <br /> `1601 East Hazelton Avenue <br /> Stockton, CA 95205 <br /> EH 05 39 Rev. 5/82 <br />