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CNI- <br /> Q) <br /> Sam juin Ptabfic Health Services Report far the month of - (o <br /> U ErwlEgnmerftl HeAh Setv <br /> 9PO Box 20D9(44S N.San Joaquin St.) Septic Tank and Cesspool <br /> Submitted by: � '�C- <br /> a <br /> Stadcton,California.95209 Cleaners Report <br /> fax4640138 AdtireSs: f85'B3 �1i�l� l <br /> Must be submitted by the 1P of each morrth <br /> CY, Date Name of Property Owner Address where work was performed type waste gal.pumped disposal site <br /> CO -3- r 2 r <br /> J <br /> O <br /> N —ta a <br /> r <br /> 3-q It ' eg_5�0-3� r S` �?s�o �r2.3 e- <br /> J <br /> YID �' �}- (.- � -- - r - ?��J c� <br /> P4 ��r Y i�i' • Cmc L P<" (� !� <br /> z <br /> u <br /> qrd Id stk_ <br /> N The following excel from the code of federal Relations.Section 40"Report must be skned by a c rporate officer who can fiY bbid the <br /> N ao paWY <br /> I certify under penalty of law that Ods docknnent and all attachments were prepared urxfer my dkectian or supervision. Q <br /> RECEIVED <br /> app 2016 <br /> EWIRONMENTAL HEALTH <br /> a PERM; ,ERWCES <br /> ■ ■ ■ ■ ■ <br />