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ti SAN.TOAQUIN COLINT'7' <br /> RECEIVE® <br /> ]lnMONMEI\tTAL HEALTH DEPARTTfl N'T MAY 2 2 2014 rthe <br /> urn this form by <br /> N © 304 East Weber Aveuue,3r4 Floor,Stockton,CA 95202-2708 12�'of each month <br /> Telephone:(209)466-3420 Far:(209)464-0138 Web:ww%v.sjgov.org/ehd <br /> ENIR RMESREL <br /> SEPTAGE CLEANER'S REPORT EVIC <br /> PEIT <br /> Company Name: C 8 C Portable Toilets, Inc. Re-part for the clr of: r <br /> f� <br /> yea <br /> P.O. Box 1523 I,, -- <br /> Riverbank, CA 95367 <br /> Company Address: Signature r,�i���. ^cam_ ct� <br /> y.,r 2ip Cade 1 <br /> All Informxllon submitted must be corn tete vccurtte .ad legible <br /> DATE VAA)F OF BUSIKESS OR ADDRESS WHERE WORK WAS DOTE GA1.1 GNS (R) Itimmun-E&. <br /> T'UMPED PROPERTY OWNEE <br /> 7LEA6E INCLUDE STREET A. DIACCTIOd, STREET RAttlE AND CITY PUMPED (G) CMASE RAA KA 41E OFTREATMEI\T,Cl atrcAL - FACILITY <br /> N � <br /> J <br /> to W Citi _ <br /> c _ ,2 517 0 <br /> co J <br /> fY <br /> > a <br /> z <br /> w Cid. <br /> 9 Oa <br /> in. <br /> 0 <br /> Ciry• <br /> ` D �h 2 <br /> Pe <br /> L m <br /> 0 Lk <br /> City <br /> D m <br /> Lo J = C4LD <br /> U v <br /> 01 <br /> N _L0033 �C k cl 1ty <br /> U <br /> O <br /> C C4. <br /> C9 Sao <br /> . i Ciry <br /> Ln1 <br /> .--� J _ __/[1 City' N <br /> .. 7- �JL4 01V <br />~ — <br /> — �- <br /> o -- -- - <br /> Cay <br /> tv " Ef HD 4Z-94 <br /> V <br /> n <br /> 8/30104 <br /> ro <br /> E <br />