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SAN JOAQUIN COUidTY <br /> m ENVIRONMENTAL HEALTH UEPAR1T ENT Return this form by <br /> 304 East Weber Avenuc,3rd floor,Stockton,CA 95202-2708 the 126 of each month <br /> CD <br /> Q Telephone:(209)468-3420 Fes:(209)464-0136 Web:www•tjgov.crg/ehd <br /> SEPTAGE CLEANER'S REPORT <br /> s <br /> Q <br /> Compnny Dame: C & C Portable Toilets, Inc. Report for th7M (h of:P.O. Box 1523 Signature: <br /> Company Address: Riverbank, CA 95367 <br /> zia coag <br /> Aif InformAtton aubmit(ed must be com lete occurate stud legible <br /> (R) viumcmuAL <br /> DATE !\AAI F.OF BUSMM OR ADDRESS WHERE WORK VIAS DONE GAIXONS CC) rRFAssrRAr ►iM IE OF TRBATMEN7 <br /> O PROPERTY OWNER PUMPFD FAC[L[TY <br /> ,.,� PIIMpEI1 PLEASE 1NCLUDC STREET a, DIRECTION, STR CET NAM AND CITY C) Cjl CAL <br /> m J Qil.. <br /> 113.3 4acl isy r <br /> 00 Q <br /> m S <br /> W J �O <br /> 0O 111 <br /> Q City <br /> N I? <br /> E Q'i [in <br /> W '� l City � ) - <br /> � <br /> O City (� <br /> GI. 1 <br /> cily <br /> ouo <br /> IL r C4 <br /> m O <br /> city o <br /> M Cv <br /> CL e <br /> 1 <br /> E <br /> O - - City <br /> .-1 m Cin o <br /> rt a' <br /> � i > <br /> O — <br /> N E 111 42-04 <br /> n 8/30104 ' <br /> til <br /> E <br />