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SAN JOAQUIN COI NTN <br /> m RNvTRowmEN 1'FAL HEALTH DEPART IENT Return this form by <br /> 304 East Weber Avenue,3"Floor, Stocklon,CA 95202-2705 the 12`b of each month <br /> Q m TeL-phonc:(209)468-3420 Fax.-(209)464-0138 Web:www.sjgoY.org/ehd <br /> a SEPTAGE CLEANER'S REPORT <br /> a. <br /> company'Name: C & C Portable Toilets, Inc. _ Report for the m Ith of: ycar� <br /> P.O. Box 1523 <br /> Company Address: Signature: �-�L�1-44 ^� <br /> Riverbank, CA 95367 74cade j <br /> All informxlion submiticd must be eom lets occuratc apd legible <br /> p ADDRESS 1VHRRE WORKNYAS DOTE GALLONS (G cKrAsETRILIBIDENrUTAJaE OFTREATM N- <br /> DATE RA1\IF OF BU3I1�'ESS OR (G) cxEAssTxAr <br /> pUMPED PRorwrYONVNRA )LEASE 1KCLUDE STREET A. DIRECTION, STREET rtAM AXD CITY PUMPED Cl curmcAL _ FACILrrV <br /> - <br /> co2 Ery. <br /> 0 <br /> o F- cit,. <br /> cv z <br /> Ld p �Itv <br /> X <br /> 2i VA) City 1i <br /> W '� / Clq� Az <br /> City G. <br /> N cry <br /> F- <br /> Cin• o <br /> 10 - <br /> Clay <br /> L0 co E I <br /> m <br /> lC at, A 10 <br /> U <br /> cz LO <br /> U 915�� 42M ° led <br /> m � 2 o 12i <br /> o cin• � <br /> city62 <br /> p J� <br /> m <br /> d- m Gtr—_ --- -- - — � F— <br /> m city > <br /> 00 i — <br /> a� <br /> m EIID 42-04 <br /> 8/3(1/04 <br />