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SAN JOAQUIN COUNTY <br /> ENWRONMENTAL HEALTH❑EPAILIME T Retu rn this form by <br /> m 304 Fast Weber Aveuuc,3id Floor,Stockton,CA 95202-2708 the I2" of each month . <br /> Ln r&-phonc:(209)468-3420 Far.:(209)464-0138 Web:www,sjgov org/chd <br /> W <br /> SEPTAGE CLEANER'S REPORT <br /> Company Name: C & C Portable Toilets, Inc. Report for the me th of: <br /> Company Address: P.O. Box 1523 <br /> Riverbank, CA 95367 2:y Cde Signature: <br /> o <br /> :r <br /> All infersunlion nubmittcd must be cum Tete accurate IIDd legible <br /> DATB KA161E OF BUSINESS OR ADDRESS WEiERE WORK WAS DONE GAIA ONS (R) ytIBIE lvrl tL <br /> (G) c1+EAsszaar f�AA1EORTRBA-T7v1E?�T <br /> lrumrFF-D PROPERTY OWNER PLEASE INCLUDE STREET %, DIRECT1nN, STREET NAML CITV PUMM C) MEA.SuL FACILITY <br /> O = <br /> N w <br /> /2 <br /> co <br /> CT) z <br /> o w <br /> (V Z trC /t D Cin <br /> firIlk C2 / �_ _ Ciry <br /> Ld 12- <br /> 1 L " o <br /> +.) M c�7 <br /> L — — - <br /> IL LD <br /> v - - <br /> U m - — City <br /> d- <br /> U o <br /> — — Cin o0 <br /> IZ <br /> N <br /> Cl) <br /> m LHD 4244 <br /> n <br /> �o <br /> E <br />