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SAN JOAQUIN PUBLIC HEALTH tlER ICES <br /> SEPTIC TANK AND CESSPOOL CLEANERS REPORT J {�Q <br /> ' M T B &i4LADDRESS 37 2•tREPQRT Ff}R 1't+E MGNTH 0 19 SUB .IT ED Y <br /> NAME OF ADDRESS WHERE GALLONS <br /> DATE PROPERTY OWNER WORK WAS DONE PUMPED WHERE CUANINGS WERE UNLOADED <br /> ��- <br /> � �c��►ch . tL�� <br /> . . ,. 00 <br /> �t G 1 <br /> *5 C w <br /> f s q n a <br /> UJO' W <br /> 1 ` <br /> ' beo nu2140 <br /> \Can -no0 <br /> . 4go <br /> DIQAJ <br /> v <br /> C7- oe. o . <br /> 0 <br /> Return by the 12th of the month to I certify under penalty of perjury that the foregoinghs true and cora <br /> San Joaquin Local Health District ' <br /> 1601 East Hazelton Avenue <br /> jzo�- <br /> Stockton, CA 95205 DATE SrGNATURE OF APPEICART <br /> EH 05 39 Rev. 5/82 <br />