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ENVIRONMENTAL: :TH DEPARTMENT /-'IN) Return r <br /> '� -arm b <br /> Q { 600 East Main Street, :kton,CA 95202-2708 � the 12'h x h mon <br /> y Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> :o- CHEMICAL TOILET CLEANERS REPORT <br /> Company Name: <br /> � �S „t Report for the month of: year <br /> Company Address: �'�,C �c�� `� Rei Signature: <br /> Street Address City Zip Cede <br /> All information submitted must be complete, accurate, and legible <br /> TOTAL NUMBER OF TOTAL VOLUME OF NAME OF TREATMENT FACILITY <br /> DATE CITY WHERE PUMPED CHEMICAL CHEMICAL TOILETS CHEMICAL TOILET WASTE WHERE CHEMICAL TOILET WASTE DISPOSED <br /> PUMPED TOILETS ARE LOCATED PUMPED IN PER SPECIFIED PUMPED PER CITY PER DATE <br /> CITY� ATE <br /> 1nD <br /> V -cv <br /> -e p <br /> ..� ��� -E a t• <br /> uJ P S <br /> a t' <br /> -1r: ; <br /> �y. <br /> I; 1. IK ' <br /> y t <br /> 11Av o1. t c3 V 0 <br /> Chemical Toilet Report <br /> EHD 42-017 <br /> 9/23/2004 <br />