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ENVIRONMENTAL vrALTH DEPARTMENT <br /> Return t' ' form by <br /> '` 600 East Main Sheet, �kton, CA 95202-2708 lh ! <br /> t'• Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.Sjgov,org/ehd the 12 k. _Ach month <br /> CHEMICAL TOILET CLEANERS REPORT <br /> mpany Name: 1i` �tsf - <br /> Report for the month of: year -)c'f(- <br /> mpany Address; 92Z ( � ,�� t f ► Q� <br /> Street Address Signature: <br /> City Zip Code <br /> Information submitted must be comIcte accurate and legible <br /> TOTAL NUMBE <br /> DATE CITY WHERE PUMPED CHEMICAL CHEMICAL TOILETS TOTAL VOLUME OF <br /> 'LIMPED TOILETS ARE LOCATED PUMPED IN SPECIFIED CHEMICAL TOILET WASTE NAME OF TREATMENT FACILITY <br /> CITY PER DATE PUMPED PER CITY PER DATE WHERE CHEMICAL TOILET WASTI;DISPOSED <br /> f'r <br /> /tooS IT,`'FRT� <br /> A 1 << r <br /> lip <br /> 17 J-1 Ito <br /> f. <br /> n <br /> ¢t r e,, <br /> !D• 1'-lG� ,/d�d�Sz� �19 jt?f„S�,�ctitrn � � <br /> aq- <br /> 42.017 <br /> soo4 <br /> Chemical Toilet Report <br />