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ENVIRONMENTA ALTH DEPARTMENT — �5 Return form by <br /> " 600 East Main Street; ;kton, CA 95202-2708 the 12" _.ach month <br /> t'• Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> CHEMICAL TOILET CLEANERS REPORT <br /> Company Name: C1_1 4-�o <br /> Report for for the month of: �(o year 1 !a <br /> Company Address: X122 ��-c� &-- ��y,y(t, 9s�Zpcl Signature: <br /> Street Address City Zip Code <br /> All information submitted must be com fete, accurate and legible <br /> DATE CITY WHERE PUMPED CHEMICALTOTAL NUMBER T TOTAL VOLUME OF <br /> CHEMICAL CHEMICAL TOIL <br /> HEMICAL TOILETS ET WASTE NAME OF TREATMENT FACILITY <br /> TOILETS ARE LOCATED PUMPED IN SPECIFIED WHERE CHEMICAL TOILET WASTE DISPOSED <br /> CITY PER DATE PUMPED PER CITY PER DATE <br /> Je,V it�N lc <br /> v-ija `���.2�OJ��Sa ICC <br /> ib PAP'aise 1 L� <br /> V -iN NW i r4D Nett+`cG U C. l cTC <br /> 3 --S-1 V <br /> ID e •T-t9- -Den(0e3 <br /> t f' ry N l e. <br /> HHD 42-017 <br /> 9/23/2004 Chemical Toilet Report <br />