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SAN JOAQUIN COUNTY <br /> EN IRONMHNTAL HL-ALTH DEPARTMENT Return this form b <br /> N m 304 East Weber Avenue,3''Floor, Stockton,CA 95202-2708 tic 12"'of each month . <br /> Q w <br /> Telephone:(209)468.3420 Far:(209)464-0138 Web:www.sjgov-erg/ehd <br /> a SEPTAGE CLEANER'S REPORT <br /> Company Name: C & C Portable Toilets, Inc. Repan for the m (hof. 0/ <br /> P.O. Box 1523 year <br /> Company Address: Signature <br /> Riverbank, CA 95367Zip�jc <br /> Alt laformittton submitted must be cum Plete, aEcurete and le iblc <br /> DATE NAAlE OF RUS11ST $OR ADDRESS WHERE WORK VIAS DONE GAIXO S (R) RIis1DENTuL <br /> {G) CREA9STRw NAME OFTRSATME.N'T ' <br /> O PUMPED PROPHRT1'OWNER PLCASS INCLUDE STREET e, DIRECTION, STREET NAM AND CITY PUMPED C) c�srnstGi FACILITY <br /> coM 4a <br /> y ^ <br /> M / L/ Cin <br /> W QJ <br /> W <br /> OZ O4' <br /> N w <br /> 7 O tl Citr <br /> Z (17 <br /> O - <br /> 0ILLi I <br /> W l , / City <br /> . e o� <br /> C' O c City /zJ 62 <br /> City �I <br /> 1 Oh. � <br /> fu CJ Coy ez <br /> L C- <br /> CD <br /> LO ins -L led s. ,� <br /> U v <br /> df m <br /> U N _. <br /> 12 0 <br /> m <br /> W \ C� _ , -Q�� _ Cinec, zz <br /> CiLya <br /> I � <br /> m — ------ -. - Cil• <br /> --- .. - ---- — f— <br /> Gly a <br /> W o E11D 42-04 <br /> n <br /> S/30104 <br /> ro <br /> E <br />