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SAN JOAQUIN COTINI"I' Return this form by <br /> m $NVrRONl Ej\'1'ALHEALTH UEPARnIENT rn <br /> to 304 East Weber Av-uc,3`�floor,Stockton,CA 95202-2708 the 12 of each month <br /> m Telephone:(209)468-3420 Fax::(209)464-013A f;'eb:wwlv.sjgov.org/ehd <br /> LL <br /> w SEPTAGE CLEANER'S REPORT yea D! <br /> c� <br /> a _. <br /> Report for the meplh of-'L' <br /> Compau�.1`Iame; C $� C Portable Toilets, Inc. �/ ,.� <br /> P.O. Box 1523 Signature: 1-"Y7•-Few <br /> Company Address: Riverbank, CA 95367 zlycaa� <br /> All Inforrnpllou submitted must be Complete, Ittcuretc and legible {Ft) pESIDCllt1A 1. <br /> ADBR1uSS\YHERE WORK WAS DOBE, GALLONS (G) cltXAssTR.tr liMIEQ['TRBATM£�T <br /> O DATE KAJUE OF BUSINTM OR PUMPED C) CllE6RGL FACILM <br /> N )`UI�ZPED PROPERTY CINYNI)iR TLEAS£ INCLDDC SYREFT K. I)IRr.CTIDN, STREET NAML CITY <br /> m C l co <br /> �O <br /> (Y) <br /> W = <br /> O <br /> o J / (�p _ A <br /> � <br /> N Z /� LL <br /> /l-L�� T[rr�t � a� <br /> Ciq <br /> Ld <br /> dCity 1' <br /> Cit <br /> Ci" z <br /> +� :5MM <br /> L cry - C- <br /> 0 oo c�-4 <br /> CD city <br /> U 'u- <br /> 03 <br /> Oil LoNT Ory -- <br /> U on o <br /> qty o <br /> LZ m i C-4 <br /> citya -- .--- <br /> E= <br /> ,9 Ciy — <br /> N <br /> C ' <br /> c ` , - <br /> N FAIT) 42-04 <br /> ro <br /> F <br />