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SAN JOAQUIN COUNTY <br /> ENVRLOWMENTAL HEALTH DEPARTWONT <br /> Return this form by <br /> 304 East WebeT Avwui,31"Floor.Stockton,CA 95202-2708 <br /> the i2`h of each month . <br /> m <br /> Telephone,(209)466-3420 Fay.(209)464-0138 li`eb:www.sjgati'-orglt:h <br /> _...-----_-.-- SEPTAGE CLEANER'S REPORT lo <br /> Complav Name: C & C portable Toilets, Inc. Repoti for the ch af: <br /> dc— year�/ <br /> P.O. Box 1523 Signature'. 1 u <br /> Company Address: Riverbank,CA 95367 rpcdc <br /> ASL inform}tloe a¢bTni ti cd must be eoln letel prturaic cad !e ibte (R) pYSOIfNML <br /> DA's KAASI?OF RLLiS1n�SS flLf ADDR09` HERE[vfl[tK vl'A5 Dt7IiE GA11�QT�5 (a) cp�w5t Tn Ir 1CA34E OnTRBATk1Fx+'[ <br /> r I PUMPED FACRATY <br /> pL3i Ei] <br /> PROPERTY OVA= YLCASC FicG,.DDC STRE[T x, DIRECTION. S-rat:[i VtArd Ar$ CITY C C"M,CAL <br /> Crm a <br /> D Q 1DC5y <br /> City (11 <br /> Z <br /> E0Y ( . n <br /> M /! <br /> � Cil}' lj..�+ _ <br /> e 0 cik, 5: �O t <br /> IA cih " <br /> N <br /> City <br /> Ctily <br /> 0 107 <br /> U,Y1 r ch). ACO <br /> YJ <br /> tr I <br /> U Nr �• dCOY <br /> QD <br /> rc �� c'ry <br /> .. iri <br /> r a [Sty <br /> O c <br /> Coy <br /> N <br /> GHD 42-04 <br /> 8[36104 <br /> i <br /> ti <br />