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-'�" ""^yrua v.uv ur' GLylf UYlUN1L41 lL4[l1LL L1y 49Lyp <br /> Septic Tank and Cesspool Cleaners Report y' L <br /> m COMPANY NAME: 1 m-i, ij�s RECEr Or �$ <br /> m COMPANVADDRESS: ,2g2Z <br /> w rS3s REPORT FOR THE MONTH OF: ,v, 28eH aeDEC 09 2011 <br /> a DATE I OR PROPERTY ADDRESS WHFRE WORK GALLONS WHERE'Gk, ANINGS'WERE UNLOADF,D <br /> OWNER WAS COMPLETED PUMPED 'cwp) <br /> I/- � �tc��is• �� / rV Lam <br /> 408,/. <br /> . <br /> ' <br /> — //�C+G/!'7 �'a�. �.�� ! � /aS // mac // ► y ' <br /> J `e'Ic nt «. �T /6GU nor c <br /> ro <br /> cha <br /> c <br /> 0 <br /> tL <br /> a <br /> a <br /> r <br /> N <br /> a <br /> m <br /> v <br /> N <br /> u� <br /> m <br /> m <br /> N <br /> ro <br /> v <br /> r, <br /> Return by the 12°ofeech month to I CERTIFY I FNDER PENALTY OFPEUR HAT THE FORG011VG IS TRUE AND CORRECT, <br /> m Eoviroumentol Heol[b bh,600 <br /> 3"Eosl Weber Ave°uq 3w Floor <br /> Stceklov,CA 95202 AT 1 c/� yry <br /> m S NA RE OF APPLICANT <br /> Sepkep Rev. 12!79 <br />