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SAN JOAQUIN COtrNTI' <br /> m n ENVIRON-htBNTAL I1FALT11 MPAR'i MMT Return this form by <br /> �a 304 East weber Avenue,3r'Floor,Stockton,CA 95202-2709 the 22"of eacb month <br /> Tele[Iho>tc:(209)466-3420 Fat:-(209)464-0138 7Yeb:www.sjgo%,.crg/t:hd <br /> SEPTAGE CLEANER'S REPORT <br /> Compau<<�Iame: C & C Portable Toilets, Inc. Report for them (hof: year <br /> a <br /> P.O_ Box 1523 / J <br /> Company Address: Riverbank, CA 95367 Signature: ��1 .1 C'- aC-�F zff <br /> �r .. <br /> �r caa� <br /> All lafermatloa s"mitrcd must be corn Itie pecurtie rDd It iblc <br /> O ADDRESS WHERE WORK WAS DONE GALLONS (G Rg A.S1E R.A rWIE OFTRRA7ME.N'T <br /> DATE NAME OF BUSIn'ESS OR (G} cnsiss txAr <br /> N rUMPED PROPEM'OWNU TLeASE INCI-0DE STRECT Ir, DIRECTION, STREET rtArdE CITY PUMPMC� �� r'ACILFT/Y' Irk/ <br /> co / f <br /> Ma <br /> it <br /> OJ t � <br /> Na Ali <br /> z <br /> 7 i!� <br /> b(y <br /> 81A46 D c5n <br /> acit,. / 2, <br /> o <br /> Cin <br /> 1] OQ A tv _ o <br /> �5 <br /> L O <br /> IL <br /> n / Ciry <br /> rn <br /> L)o qty _ <br /> U n Cry o ;. <br /> ci.. <br /> Ln, 1/ cel <br /> Ery <br /> E <br /> 7 Cita. � <br /> O Qtr <br /> J — F— • <br /> City <br /> C,ty -— <br /> nI E11D 4744 <br /> ro 8/30/04 <br /> E <br />