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�o `��"'•.eQ SAN JOAQUIN COUNTY <br /> 2• y ENVIRONMENTAL HEALTH DEPARTMENT Return this form by <br /> h. < 600 East Main Street,Stockton,CA 95202-2708 the 12th of each month <br /> Telephone:ne:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> 0. `P CHEMICAL TOILET CLEANERS REPORT <br /> Company Name: Report for the month of: year <br /> Company Address: Signature: <br /> Street Address City Zip Code <br /> All information submitted must be complete, accurate, 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 /> PUMPED TOILETS ARE LOCATED PUMPED IN SPECIFIED PUMPED PER CITY PER DATE WHERE CHEMICAL TOILET WASTE DISPOSED <br /> CITY PER DATE <br /> w lu&ndl f- V7 <br /> 1b 1 qS2- 946 7 <br /> It (/rw pA -I S � SQ <br /> V1W 00 <br /> MAO <br /> U-w S- <br /> S !/ IV � <br /> R ! _ v-W (gyp <br /> tab <br /> t <br /> EHD 42-017 <br /> Chemical Toilet Report <br /> 9/23/2004 <br />