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SAN JOAQUIN COLrrn-Y - <br /> m FNVrk0NMFNTAL HEkLTH DEPARTmE r T Return this form by <br /> CD 304 Salt Weber Avenue,3r°Floor,Stockton,CA 95202-2708 the 12"`of each month <br /> m Tetephonc:(209)468-3420 Far-(209)464-0138 We&www.sjgov.crg/ehd <br /> • w <br /> a SEF1AGE CLEANER'S REPORT <br /> Company Name: C & C Portable Toilets, Inc. Report for the me dl aG ycarc C/` <br /> P.O. Box 1523 - <br /> Company Address, Riverbank, CA 95367 Signature. ni 1,f�!Lcc, tt�r <br /> .,., Zip caac e i <br /> All tnformxliou submitled must be complete, ■ccurste and legible r <br /> ADDABSS\Vf3ERF�vORK11`AS DOTE GALLO>`S {R) RUMENllAL <br /> DATE NAAMOFHUSMSSOR (G) CKWVTRAF nAMEORTREATMs?,T <br /> PUMPRD FROPERI-l'O\YNSR PUMFED FACILM <br /> O = PLEASE In C4lt0E STRC ET w, DIRECTIDII, S?R ELT IiAA1E AND CITY CJ CHEMICAL <br /> N a a (�O A qQ - city <br /> m w <br /> CO z wry. <br /> M n <br /> CO E% _ e fl na <br /> o w <br /> N z ci <br /> 0 t l <br /> r-t ,,//)� n <br /> b i-V . - <br /> 0 <br /> City <br /> � z <br /> i� 00 City - <br /> L . - <br /> O , <br /> IL LO <br /> v -- <br /> U °' 4ry <br /> oL N — <br /> U o <br /> m <br /> City <br /> 10 M City <br /> Ln a <br /> ,.., N Cat' --- --- <br /> y CU'Y <br /> t a <br /> i 11D 42-04 <br /> N $/30/04 ' <br /> V <br /> N <br /> n <br /> 10 <br /> E <br />