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REcf <br /> q; ENvIRONMENTA 7ALTH DEPARTMENT MAR gReturn form by <br /> Lkiy <br /> `�. ' 600 East Main Street; -,kton, CA 95202-2708 the 12"L -.ach month <br /> •: �• Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehdNVlRCNME1VTAL <br /> �qc <br /> PERMIT/SES HES",CHEMICAL TOILET CLEANERS REPORT �C <br /> Company Name: <br /> Report for the month of: year i (o <br /> Company Address: ci22 Le� -�- � (rte 9SLo9 Signature: n — <br /> Street Address City Zip Coda <br /> All Information submitted must be complete, accurate and legible <br /> TOTAL NUMBER OF <br /> DATE CITY WHERE PUMPED CHEMICAL CHEMICAL TOILETS TOTAL VOLUME OF NAME OF TREATMENT FACILITY <br /> PUMPED TOILETS ARE LOCATED PUMPED IN SPECIFIED CHEMICAL TOILET WASTE WHERE CHEMICAL TOILET WASTE DISPOSED <br /> CITY PER DATE PUMPED PER CITY PER DATE <br /> C 1v <br /> cC . is <br /> V-vJ -� 5 <br /> 1 - 2- 1jIs� Pc M ivt r�z <br /> 0.2 G.A V- K K, 2,-'r c,e S <br /> ttu S tL i� A15 <br /> i - 13-i10 -Lk) ( 00 q A15 <br /> - l -1('P V"LO <br /> awc 1 2&" Ais <br /> e i <br /> " _t I,N' <br /> V itX� P1" <br /> I G TS DlS <br /> -W A VvDn ick oAi <br /> Jv0 p <br /> Als <br /> 1-2- <br /> - <br /> -i(o V-Lk) c;w 4e(L bG2� \bb <br /> 2-- 2- I(Q Re 1to S'ev i00 <br /> ERD 42-017 <br />