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SAN JOAQUIN COLTrn' <br /> by <br /> O m ENV)RONMLt�TAL HEALTH DEPARThfENT Return this Corm on <br /> f h <br /> 304 East Weber Avcuuc,3`d Floor, Stockton,CA 95202-2708 the 12`�of Tach mon <br /> CD <br /> Telephone:(209)468-3420 Fax (209)464-0138 ff efi:www.%jgov-org/chd <br /> w SRPTAGE CLEANER'S REPORT / <br /> - -- Report far the m ib (if: Myear�P_� <br /> CotnitanyName: C & C Portable Toilets, Inc. <br /> P.O. Box 1523 Signature: A —k—I Z <br /> Company Address: Riverbank, CA 95367 Zip Cade <br /> ASL infermAtLon submiNcd must be corn lett pccurc(c mad Ic ibie {R) RvanEMUL <br /> O DA fE l�e�i7sSE OF HU31nESS OR ADDRESS)MERE%VORK 11'AS DOKE GALLONS (G) CKWAS MW NAME OR TREATMEN-f- <br /> NYUhSPflD PRoPjZRT'V ONVNER r L e A 6 E 1 4 C L D D E STREET f. DIRECTION• S T A E L T HAM A X D CITY QUMPbp C) CXrM[CAC FACILITY <br /> 0 )3 <br /> =o mN <br /> mHzz <br /> / <br /> o� <br /> ritV <br /> 72 p <br /> Ldw <br /> [' my /YJ <br /> cin- <br /> ? c`ry r, <br /> lCin• � <br /> / o <br /> --- <br /> a. <br /> z ,� <br /> cit).- Ln <br /> as v D O �h <br /> GD 1�. o <br /> N n C-4 <br /> Cloy _ <br /> o ' � Cary. <br /> m <br /> CiLy <br /> EUD 42-04 <br /> n 8/30104 <br /> �o <br />