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SAN JOAQUIN UOUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form by <br /> 600 East Main Street, Stockton,CA 95202-2708' the 12'h of each month <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> CHEMICAL TOILET CLEANERS REPORT <br /> Company Name: Report for the month of: year <br /> Company Address: Signature: <br /> Street Address T 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 TREATMENT FACILITY <br /> PUMPED TOILETS ARE LOCATED PUMPED IN SPECIFIED PUMPED PER CITY PER DATE WHERE CHEMICAL TOILET WASTEE DISPOSED <br /> CITY PER DATE <br /> 160 <br /> s70 7 <br /> 2 d V-to -40 <br /> Is ri �Do , <br /> 40c _-141<00 <br /> St;Le, :k IIID <br /> Cog- <br /> sco <br /> EHD 42-017 \� Chemical Toilet Report <br /> 9/23/2004 <br />