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SAN JOAQUIN PUBLIC HEALTH JERVICES ' <br /> SEPTIC TANK AND CESSPOOL CLEANERS REPORT <br /> REPORT FflOL- <br /> R T* MONTH OF l9 SUBMITTED BY 1 � AOORESS .+� <br /> NAME OF ADDRESS WHERE GALLONS <br /> DATE PROPERTY OWNER WORK WAS DONE PUMPED WHERE CLEANINGS WERE UNLOADED <br /> �.E=y <br /> 200 2& 2 0 <br /> tt. <br /> IJ <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 <br /> DATC- SIGNATURE-OF APPLICANT- <br /> EH 05 39 Rev. 5/82 <br />