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Z ENVIRONMENTAL 1-7rALTH DEPARTMENT 1r� <br /> Return t' form by <br /> 600 East Main Street, ckton,CA 95202-2708 the 12", aeh month <br /> ?. <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov,org/ehd <br /> CHEMICAL TOILET CLEANERS REPORT <br /> Ipany Name: Report for the month of: 3-J -tS year <br /> Ipany Address: Signature: <br /> Street Address City Zip Code <br /> formation submitted must be complete, accurate, and legible <br /> TOTAL NUMBER OF TOTAL VOLUME OF <br /> )ATE CITY WHERE PUMPED CHEMICAL CHEMICAL TOILETS NAME OF TREATMENT FACILITY <br /> IMPED TOILETS ARE LOCATED PUMPED IN SPECIFIED CHEMICAL TOILET WASTE WHERE CHEMICAL TOILET WASTE DISPOSED <br /> CITY PER DATE PUMPED PER CITY PER DATE <br /> V -tcj <br /> -1S <br /> v -w I !�� v -U) <br /> 40 210 <br /> s3 -- k�!!tSLj V-4'J <br /> D- i sI S c - 1360 V.-u) <br /> LIS- 4,e, ��I,}� S a(.�� CCV22 ctfZ� ti21i(CL <br /> Va) P ;JL P L (,sic v -to <br /> e v <br /> S -F',we2 p, 2z%wS - V-tv <br /> ftz 24-0 V-0 <br /> Kt S <br /> J <br /> q I Chemical Toilet Report <br />