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ENVIRONMENTAL ALTH DEPARTMENT <br /> 600 East Main Street, �kton, ?5202-2708 Return t' ' arm <br /> the 12 c a., m h <br /> Telephone:(209)468-3420 Fax:(209)464-01 Web: www.sjgov.org/ehd <br /> q� `a CHEMICAL T-MLET-C-L'EANHRS SRT <br /> mpany Name: ��� '�R: tae+t(��s t11 Q INt; � �� d1Cf �e2(/rie� <br /> Report for the month of: 1- /6 - year <br /> mpany Address; 2 <br /> � r9s2t�J Signature: ��<Ji�,u.ty <br /> Street Address City Zip Code <br /> Information submitted must be com tete accurate and legible <br /> TOTAL NUMBER OF TOTAL VOLUME OF <br /> DATE CITY WHERE PUMPED CHEMICAL CHEMICAL TOILETS NAME OF TREATMENT FACILITY <br /> 'UMPED TOILETS ARE LOCATED PUMPED IN SPECIFIED CHEMICAL TOILET WASTE <br /> I -1 f CITY PER DATE PUMPED PER CITY PER DATE WHERE CHEMICAL TOILET WASTE DISPOSED <br /> 3'! we12 v - Gl� f�r.S P[ /w <br /> 3-Itvti>a Ldvc . - kio2,A (ac) - <br /> 'V -Ui 'Boss �(Y) <br /> �u1 �P CJU nlc— <br /> ���P - <br /> I I -I v-u.) DD <br /> -1.3-40 <br /> -{-i-i� <br /> INA <br /> 4-119-1(101 �o2 S - klri zs j>�� ijS <br /> to <br /> -m-1 uj1 rPm ZDD . <br /> l{-1,q-It <br /> +zb-I' '-j�L; tz,j-zi-,ND l�c� <br /> - <br /> r // 'olIs� ref- \_FIs -,Boca <br /> 42-017 - �P 1 S 1 e�( �ili i NT�°2 { )a - <br /> L + <br /> 20045-- / f 7 N J�� �I (�(��`r� �V - Chemical Toilet Report <br /> r7 <br />