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SAT JOAQUIN COMP Return this form by <br /> CD -ONMENITAL HEALTH DEPART im' <br /> a 304 East Wt-ber Avenuc,3id Floor, Stockton,CA 95202-270A the 12`�of each month <br /> CD <br /> Telephone:(209)466-3420 Fax.:(209)464-0138 Web:www.sjgov.orglch <br /> CL Ld <br /> SE14AGE CLEANER'S REPORT <br /> Com ani'Mame: C & C Portable Toilets, Inc. Report for the to th (If-. year <br /> P.O. Box 1523 Signature: i�y1 ti.c6 c�t�i 70I <br /> Company Address: Riverbank, CA 95367 7ipG a& <br /> All iRtDrmAliGn s¢bmitttd must be corn pittt, per-urtie pod Ic iblt (R) RK5IurNTLAt <br /> DATE NAME OF BUSINESS OR ADDRESS WHERE WORK WAS DOTE GA1IPED (G) cREASETRM ���OF FACILITY il;�7 ' <br /> PROPERTY O\YNRII PUMPED rAC[LITY <br /> .--i p1Jlv¢'E.D pLF_ASL INCLUDE SSREFT �� DIRC CTIOt1, 5T'R LET r2AML CITY CJ CtICMIGtt <br /> (U -j / / to <br /> ' tt <br /> n 1 <br /> cm*) Gn <br /> i ` V - I -- <br /> oo cam_ _ - <br /> J / <br /> oo' ►a- <br /> N --u- <br /> Ci1v (o <br /> Z <br /> p <br /> H T <br /> w <br /> City <br /> ciy <br /> N + rn <br /> o <br /> � o <br /> city <br /> O — <br /> a m C-4v _ <br /> L) W <br /> v <br /> dJ m my <br /> U N Cita o <br /> GN _ rn <br /> D ---- City <br /> .. 61V - -- -- --T— _ <br /> O m Giy— <br /> city <br /> r, © E11D 42-04 <br /> n R/30/04CMf <br /> Io , <br /> F <br />