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SAN JOAQUlN COtTNTY <br /> m i:NvrRoNma\n'AL HEALTH DE:PARiTiENT Return this form by <br /> 304 East Weber Ave iuc,3'4 Fioor, Stockton,CA 95202-2708 the 12`''of each month <br /> .a m <br /> ,4 reL-phunc:(209)465-3420 Fa,.(209)464-013R Web:ww%v.Sjgay.org/chd <br /> - a SEP•CAGT CLEANER'S REPORT ss�� <br /> Company Name: C & C Portable Toilets, Inc. Rcpnrt for them tb of: _ <br /> year <br /> P.O. Box 1523 � <br /> Company Address: Riverbank, CA 95367 <br /> Zip Cad. <br /> l <br /> AIL infOrinAllou suLmilted must be cum lete aceurrte and legible <br /> WDATEr;A1+SF OF RUSIKESS OR ADDRESS WHERE WORK WAS DONE GALLONS �i c¢c�tits� K MtE OrTREkTMF-K-r <br /> PROPBRT'y01VNER PLEASE IKCLUDC STREET If, DIRECTION, STRLET HAMLC1 TY POMPTU C) cmrmiCAL FAC[LM <br /> m w Q <br /> ao City / <br /> oo <br /> ztl� 2 Lc cin_ <br /> O <br /> s city <br /> > <br /> z I/ <br /> w <br /> A -4 �/ <br /> cif• c <br /> CCD <br /> In ( O <br /> N <br /> ru <br /> Z <br /> +,y Cq city - <br /> - a <br /> L r+0 ED <br /> c� <br /> !L � Lit). — cv <br /> "a <br /> U m _ city _ <br /> m -- <br /> oL N �_ <br /> U _. C0- <br /> CV <br /> C9 city _ <br /> rI cc; <br /> rd <br /> O City � <br /> City0 C14 <br /> E <br /> W cuy <br /> R' E,JID 42-04 <br /> $/30/04 <br /> n <br /> M <br /> E <br />