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RECEIVEDSAN JOAQUIN COUNTY <br /> FNVIRON►riENTAL H-EALTH DEPARTNiENT Return this Lorin by <br /> DEC 0 9 2015 304 Fast WebeT Avcuuc,3`"Floor, Stockton,CA 95202 2708 <br /> the 12`t'of each month <br /> �t Telephone:(209)466-3420 Fax_(209)464-0138 Web:www-sj90'L'-0r9/Chd <br /> 4- a ENVIRONMENTAL HEALTH SEA PTAGE CLEANER'S REPORT <br /> n. PERb�?IT/SERVIOES Report for the th of. / /� yrarc <br /> Compaxly Name: C & C Portable Toilets, Inc. <br /> P.O. Box 1523 Signature:��,���%'Z 14.A <br /> Inc- <br /> Company Address: CA 95367 �P�d� <br /> Riverbank, _ <br /> Ail information su6mltted most he com Iete aecurafe and legib" (R) DgSIDENn4L <br /> ADURI„SS WHERE WO1tKM'AS ROTE GALLONS (G) CRIASrTRAr WaE ORTRFA'IMaNY <br /> DATE NMIE OF HUSIIrTSS OR PUMPED C) CSi FINICAL FACILM <br /> O p� PROPERTY OAPNEIL (LEASE INCLUDE STRECT x, DIRECTION, STA GCT IdAML AND CITY a-� J <br /> i ' <br /> J(U <br /> Ct}' d` r�1 — - <br /> G,CO — <br /> m Xn ' <br /> 0o a <br /> m <br /> wCi �- <br /> N z � <br /> O s JG` aty <br /> H <br /> Z � City _ <br /> a f <br /> r <br /> t Ci <br /> Z <br /> i <br /> -3 b pity ` <br /> N Cin• <br /> — o <br /> City _ o <br /> z <br /> City <br /> L •� <br /> O m pt). — Cr <br /> EL <br /> W AC), <br /> U O o <br /> City <br /> CL city <br /> City _ — o <br /> l9 City <br /> -4 m ---- --- — <br /> In CJ `'n -o <br /> cr) �D L11D 4244 — <br /> 813 010 4 V <br /> o <br /> v <br /> Q <br />