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S301AH3S/IIWk#Sd <br /> KLW3HTVLN3YYN0UVj <br /> / Septic Tank and Cesspool Cleaners Report' I <br /> COMPANY NAM <br /> Et r'~ /z-5 •-- 1107.. L a Nnr C {�, 1 <br /> m 'COMPANY ADDRESS: �Q"!�_- c2,c ,,, g o rs �� a s• X 535i�`7�� <br /> w REPORT FOR THE MONTH OF: <br /> Q <br /> 3nI30 ' <br /> 3H <br /> Q <br /> DATE NAME OF PROPERTY ADDRESS WHERE WORK GALLONS WHERE CLEANINGS WERE UNLOADED <br /> WAS COMPLETED PUMPED <br /> R'dA, 4 1/&&/ U/, tr, W� ft 2,p &0 <br /> 3v,0 `r <br /> X. <br /> a - f <br /> r <br /> N <br /> m <br /> N <br /> Lo <br /> CDN <br /> m <br /> Return by the 12'"of eaeh month to 1 CERTIFY VINDER PENALTY OF PE HAT THE RGOITIIG IS TRI1E AND CpRRG•Cl, <br /> 04 Environmental Health Divi&6n <br /> N ` / <br /> 304 East Weber Avenge,3'+Floor - 2—� f C C <br /> stoetrton,CA 95202 OATE SrGNA 4F APPLICANT / G <br /> L <br /> CD SepRep Rev.1209 <br />