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ENVIRONMENTAL zI�H DEPARTMENT Return t"Olin by <br /> the 12th� moni <br /> 600 East Main Street., on, CA 95202-2708 <br /> Telephone:(209)468-3420 Fax:(209)464-0I38 Web:www.sjgov.org/ehd <br /> CHEMICAL TOILET CLEANERS REPORT _ ,i_ 1. <br /> Report for the month of: Year <br /> Company Name: <br /> Signature: <br /> Company Address: City zip Code <br /> Street Address <br /> All information submitted must be complete, accurate, and legible <br /> TOTAL NUMBER OF TOTAL VOLUME OF NAME OF TREATMENT FACILITY <br /> DATECITY WHERE PUMPED CHEMICAL CHEMICAL TOILETS CHEMICAL TOILET WASTE WHERE CHEMICAL TOILET WASTE DISPOSED <br /> PUMPED TOILETS ARE LOCATED PUMPED IN SPECIFIED PUMPED PER CITY PER DATE <br /> CITY PER DATE <br /> w <br /> S S <br /> -Ave, <br /> -7- 466 <br /> i level �iY�»f- gra <br /> 4M /ice r <br /> f <br /> Al eLC z/L <br /> c�VJ <br /> Chemical Toilet Report <br /> EM 42-017 <br /> 9/23/2004 <br />