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ENVIRONMENTAL u"ALTH DEPARTMENT I - <br /> h [ Return t' ' form by <br /> { 600 East Main Street �kton,CA 95202-2708 ! A 0 the 12`h ach month <br /> ,. Telephone:(209)468-3420 Fax:(209)464-0138 Web: www.sjgov.org/ehd <br /> CHEMICALTOILETCLEAN REPORT <br /> 'Ulf•.5� 1� ���� /�Itiurtl� :� --r�ccr �c�I�C.Li cZ • �r�S��t,�. <br /> Report for the mouth of: year <br /> tress: `�zL 4 �' %Z14 '4iC ,11/ J <br /> Street Address/ City Zip Code Signature: � <br /> n submitted must be complete, accurate and legible <br /> TOTAL NUMBER OF TOTAL VOLUME OF <br /> CITY WHERE PUMPED CHEMICAL CHEMICAL TOILETS CHEMICAL TOILET WASTE NAME OF TREATMENT FACILITY <br /> TOILETS ARE LOCATED PUMPED IN SPECIFIED PUMPED PER CITY PER DATE WHERE CHEMICAL TOILET WASTE DISPOSED <br /> CITY PER DATE <br /> ZAIS <br /> A& <br /> c%eg 6v <br /> P_w/'!/.Fart ' <br /> Chemical Toilet Report <br />