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ENVIRONMENTAL TTDEPARTMENT A ^ALTH D <br /> Return '' ' form by <br /> 600 East Main Stree ckton, CA 95202-2708 the 12t1 4ch month <br /> . y Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> �qC FyOR�`P CHEMICAL TOILET CLEANERS REPORT <br /> Company Name: Qex� <br /> Report for the month of: 1 ` j -1(o year 1 <br /> Company Address: _ C1z2Z 6et,-� s44- Signature: -7-�-2 LOI-��— <br /> Street Address City Zip Code <br /> All information submitted must be complete, accurate, and legible <br /> DATE CITY WHERE PUMPED CHEMICAL TOTAL NUMBER OF TOTAL VOLUME OFCHEMICAL TOILETS CHEMICAL TOILET WASTE NAME OF TREATMENT FACILITY <br /> PUMPED TOILETS ARE LOCATED PUMPED IN SPECIFIED PUMPED PER CITY PER DATE WHERE CHEMICAL TOILET WASTE DISPOSED <br /> CITY PER DATE <br /> 31� v-w N- 2q _ <br /> V —L4) P 1 l�Rv"ot [ - <br /> Z <br /> ` S c N 1cX' <br /> v <br /> `r II "� -21 +^LS oil Zp0 - <br /> Z-�3 'I(o v-w ILRA - <br /> ' Q Iz,„�4. �C')o <br /> ��1`� iso � -���5 �•� [I�r�-5' <br /> Jam. �`�, - � L.�L.l�i-� '.Y G',y�\U/�' •v J <br /> 2zo Al 13 <br /> co <br /> ZZ'�W V -W 3uZ> c oV <br /> �c tie � :ntT <br /> tS <br /> Z5 -I V -1iti p�,t 1(? <br /> EHD 42-017 <br /> 9/23/2004 Chemical Toilet Report <br />