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SAID JOAQUIN COUNTY <br /> m E�NvTRONmF-h17-AL HEALTH DEPARITfETT Return this form <br /> 304 East Weber Avenuc,3'4 Floor,Stockton,CA 95202-2703 <br /> lite 12"'of each mon <br /> th <br /> m <br /> • Telephone:(209)468•3420 Fax:(209)464-0136 T3'eh:wwFv,sjgot,.orglch <br /> Q <br /> 0 SEPTAGE CTX AN <br /> REPORT <br /> a <br /> a <br /> COm ani•Name: C $ C Portable Toilets, Inc. Report for the tlt cif: Mmd "year L/ 3 <br /> P <br /> P.O. BOX 1523 Signature..=- �A C)( 2 �I <br /> Company Address: Riverbank, CA 95367c.a. <br /> All infnrmAtion submitted must be corn tete recuretc rod le ible (R) 1R1B1DFtn&L <br /> DAZE t:AI�IP OF BUSIKES3 OR ADDRESS WHERE WORK WAS DOBE GALLOKS (G) Cru.[SETwtf t�ANtF:OPTR6ATMShT <br /> PROPERTY 01MIt YDMP ED FAC[LfrY <br /> .--1 pUtvffED TLCA 51; 1KCL[lAC S7R[cT f, DtRECTIOtr, STRL6T NAML CITY (C) Gli <br /> AZ ' <br /> (T7 J - <br /> a) <br /> m = Q <br /> 00 —C',— - <br /> o <br /> CU w1 Cita /V�- <br /> Z J \ to <br /> 0 / City <br /> Oreq <br /> Cid. <br /> Cip- i Iff�lG; <br /> Ln o <br /> - tv ( <br /> N <br /> I Clly � - - ._- :20- <br /> 3,66 <br /> 20-3 - <br /> L co City _ a- <br /> O m - Z <br /> u- m GSty <br /> 7t cr <br /> L) �- <br /> d- <br /> U m <br /> (V Cffi. o <br /> M <br /> toGly ( - <br /> .. C;ly —T— <br /> o mCiLy - - <br /> m Cvlr <br /> LID E11D 4244 ' <br /> V <br /> n 8/30/04 ' <br /> rp <br /> E <br />