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-1 SAN JOAQUIN COUNTY <br /> HNVIRONME1\''7AL HEALTH DEPARniLtzr Return this form by <br /> m 304 East Weber A,,•euuc,3'd Ficor,Stockton,CA 95202-2705 the 12'h of each month <br /> N TelephoKc;(209)468-3420 Fax::(209)464-0139 Web:ww;Y.sjgov.org/chd <br /> a SEPTAGE CLEANER'S REPORT <br /> Compau}•Name; C & C Portable Toilets, Inc. Report for the m th of_� <br /> P.O. Box 1523 <br /> 2;y coe� }ear v/d� <br /> Company Address: ` --- �-_�/� <br /> Riverbank, CA 95367 Signature: _•C�'2 � u.�o' <br /> - <br /> All Inforinxllan submitted must be complete, pccurlte find legible <br /> DATE NAME OF RUSIKESS OR ADDRESS WHERE WORK MIAS DOTE GALLONS (R) RgCIDCNr7AL <br /> (G) GarMrTRAr M01F.OrTREATMENT <br /> O pUtJIPED PROPBI2Tl'O\YNER PLEASE INCLUDE 57RLST K. DIRLCTIOt1, 37ALiT NAML CITY PUMPED C) FACILITY <br /> Nd / 10 G ju a- <br /> (T) W MM r c_ a'o• / <br /> CO z L <br /> N Z <br /> kelia"-L'4 14a can <br /> �- a �,(Y <br /> w l Z -- <br /> d - <br /> c"y2cG m <br /> v1o <br /> N <br /> _ .fl <br /> o <br /> ro <br /> p CD c;y <br /> L - o0 <br /> O m C-4 <br /> EL chy <br /> LD - t� <br /> v <br /> U ny <br /> oa m _ <br /> U N <br /> Ckv o <br /> Gly 00 <br /> !Zn City <br /> Ln <br /> QlV <br /> .. <br /> 014 - <br /> 7J <br /> Coy <br /> a� <br /> y <br /> 0o EHD 42-114 - <br /> '' 8110/04 <br /> n , <br /> d i <br /> ro <br /> E <br />