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� "^ / ENVIRONMENTAL H "THDEPARTMENT RECEIVE Return thiy`^rm by <br /> +� ` U 600 East Main Street,Sf on,CA 95202-2708 the 12ta oft. a month <br /> " � Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.orWehd DEC 29 2011 <br /> c roil <br /> q�/F00.N� CHEMICAL TOILET CLEANERS REPORT <br /> tJEN�I - MENTAL H o, / <br /> Company Name: '� 3 RAS / p Report ort.� RtA ) f Year /l <br /> Company Address: `�22 btta L� K �n Signature: <br /> Street Address City Zip Code <br /> All information submitted must be complete, see urate, and legible <br /> TOTAL NUMBER OF TOTAL VOLUME OF <br /> DATE CITY WHERE PUMPED CHEMICAL CHEMICAL TOILETS CHEMICAL TOILET WASTE NAME OF TREATMENT FACILITY <br /> WHERE CHEMICAL TOILET WASTE DISPOSED <br /> PUMPED TOILETS ARE LOCATED PUMPED IN SPECIFIED PUMPED PER CITY PER DATE <br /> CITY PER DATE <br /> 64, <br /> 11l0 - <br /> Zs -/ v - w <br /> 27 1I V-60 !1b v - w N.- � <br /> 9 .21 .11 'wet. <br /> x-30 Ft cm e. - - L.4? S <br /> -3arlell• 1 <br /> /tt Z- lr j <br /> 1,N) C <br /> l c114D <br /> D 2 l r M� l Z4t S (4S ion, <br /> v-uJ Go v -w -lam <br /> — 240 w/ rru v <br /> lSl< s —so - — .fit l4 — <br /> /0 S lI Ovea '�a�t uv - <br /> t+ -is-J/ ja-z/wt � - /da D i <br /> Chemical Toilet Repan <br /> GHD JZ-017 <br /> 91232oon <br />