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-1 .SAN JOAQUIN Cowry <br /> co I <br /> ENVIRONMENTAL.HEALTH DEPAR- MiENT Return this form by <br /> O m 304 East Weber Avenue,3'"Plow,Stockton,CA 95202-2708 the 12'h of each month . <br /> Q Telephone;(209)468.3420 Fax.(209)464-0138 Web:www.sjgo-v.org/chd <br /> w <br /> SEPTAGE CLEANER'S REPORT / <br /> Company Name: C & C Portable Toilets, Inc. Report for the m Ith or: �� )-c <br /> Company <br /> 3 <br /> Pziy caa� <br /> 0• Box 1523 <br /> Company Address: <br /> Riverbank, CA 95367 Signature:_ ,zj/14.�; — �E,V <br /> 10; <br /> All intormlttiou submitted must be complete, accuritc and le iblc <br /> DATE NAME OB BUSMSM <br /> S OR ADDRESS WHERE WORK DOTE GALLONS (R) iwsm IAL <br /> O YOR (G) CREASE TRAP <br /> MARIE OfT[iSATM£�T <br /> i = lPED PROPERTYO�VIYEIt PLEASE I►:CLODC STREET K. DIRECTION, STRELT VAMC CITY- PUMPED C) CNMUCAL FACILr" <br /> M w <br /> a) J e'c___ cin <br /> N w 1 / <br /> z cin <br /> o <br /> Pi 6 <br /> z -- <br /> Lij <br /> A4 r&A Ciq° <br /> � <br /> Ci" roea. <br /> 0 <br /> W C `o <br /> (2 cc Atv C� <br /> ru S+ z <br /> � <br /> �— �'y <br /> L co <br /> O .moi — city <br /> iL m <br /> LD - - <br /> U v - <br /> m <br /> U cco <br /> 0 <br /> Cki• <br /> Cin_ <br /> tZ .. <br /> O lfl <br /> tU - -- City - is <br /> Chy <br /> m <br /> 04 - Cite �— <br /> • 00 <br /> m MID 42-04 I <br /> n 8/30/04 <br /> tv <br /> E <br />