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SAM JOAQUIN LOCAL HEALTH DISTRICT <br /> � <br /> SEPTIC TANK AND CES POOL CLEANERS REPORTda i�l Jr-u 1631 l <br /> REPORT F{YR THE MONTH OF <br /> UBMITTED gY ADDRESS �v 933 .67--17 <br /> NAME OF J; ADDRESS WHERE GALLONS ; <br /> DATE. 'PROPERTY OWNER WORK WAS DONE PUMPED WHERE CLEANINGS WERE UNLOADED <br /> zz <br /> fIvy' <br /> r � 7 <br /> « � 62 AL 2=0 <br /> © o <br /> A4/ F414 <br /> 1 <br /> Z <br /> V <br /> rpy <br /> Q I lC�Q #� <br /> Cnk� Y I certify under penalty of perjury that , foregoing is true and correct. <br /> !De(�Gt�t m ent —DATE %� k G E APPLILANI <br /> 600 Oa4-7L T1'l LUJYLr , ���, I30�C 1 f54 500 <br />