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SAN JOAQUIN COUNTY <br /> m ENWRONMENITAL HEALTH DEPARTIfWT Retura this form by <br /> N 304 East Weber Avemuc,3'd HOW,Stockton,CA 95202-2708 the 12 of each month <br /> Q Telep)tonc:(209)468.3420 Far:(209)464-0138 r3leb:wwjv.sjgoy.org/ehd <br /> W <br /> a _ _ <br /> SEP'TAGE CLEANER'S REPORT <br /> CpmpauyI�Iame: C & C Portable Toilets, Inc. Report Ear the me (11 af: year <br /> P-O. Box 1523f <br /> Company Address: Riverbank, CA 95367 Zip Cude Signature: �-yl� u-k 7-V <br /> - y <br /> It lDformAiL011 submitted must be complete, occurilc and le ible <br /> (R) RVAIG EMU <br /> O DATE KAME OF BUSINTSS OR ADDRESS\VEMRE WORKVI'AS DONE GALLONS tG) ct rAssTRAT 1�AA1F.OlZTRBAThIE?�'r <br /> '" PUMPED PROPERTY OWNER r L C A S E I K C L O D C STREET 4. D I R E CT e O Iv, STREET NAM AND CITY PUMPED C) csn-'acnt- FACILITY <br /> � 96233 ,,. <br /> co S Gey <br /> O <br /> C a � �t►. <br /> W 67 z Qce _ cth <br /> o <br /> L�{� Gti <br /> z l Mc ALa!3tLz* c;,,. <br /> 41 <br /> o � <br /> CU <br /> f o <br /> 1-1 ' <br /> -0 – Gu_ <br /> z <br /> M <br /> 4-) Qty <br /> L IOCD <br /> EL0 co <br /> I / <br /> U 2X E1221 oty /i/ Yj Lc" <br /> as d / <br /> U co co -Ire Rry o <br /> cq 1 2 `" <br /> M <br /> o <br /> C;tv <br /> -- <br /> tD <br /> CD Ci h' <br /> CV <br /> co <br /> City > <br /> M \ i — <br /> LxD 42-04 <br /> M 8/30104 <br /> F <br />