Laserfiche WebLink
y ENVIRONMENTAL HFALTH DEPARTMENT Return th►c form by <br /> z� - <br /> { 600 East Main Street, ,,ton, CA 95202-2708the 12'h o zh month <br /> :. Telephone:(209)468-3420 Fax:(20y)464-0138 Web:www.sjgov.org/ehd <br /> CHEMICAL/TOp�ILET CLEANERS REPORT <br /> zany Name: Report for the month of. � �'" year <br /> tany Address: Signature: <br /> Street Address City Zip Code <br /> ormation submitted must be complete, accurate, and legible <br /> TOTAL NUMBER OF TOTAL VOLUME OF <br /> .TE CITY WHERE PUMPED CHEMICAL CHEMICAL TOILETS CHEMICAL TOILET WASTE NAME OF TREATMENT FACILITY <br /> IPED TOILETS ARE LOCATED PUMPED IN SPECIFIED PUMPED PER CITY PER DATE WHERE CHEMICAL TOILET WASTE DISPOSED <br /> CITY PER DATE <br /> 177 a/Lclw <br /> -/S d-iv V -40 <br /> a,;03hom 5750 n2;S v lv r a <br /> 'S Gt/ld rSe- kiN <br /> r5- peiuAAWiJ -- / 60 - <br /> ao 11 wl(k 2-4�) v-to <br /> -,� d z '7a- v <br /> �s c .W <br /> - 1 S7 4- U5 - ,- V _ <br /> td <br /> - 15 <br /> .;s /<,LJ< S I elS <br /> - r i vadLLIL &F71%i- 1 I LZ v- U) <br /> 's V -'-0 I )OD v-0) <br /> I s pa s 4j V' V-uD <br /> s e h© 660 �br� <br /> - I s �n+�.v'✓ nom.R.r r•ea.- I IIY� 6/- <br /> )17 Chemical Toilet Report <br /> I <br />