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JAN JUAVUIN I.UUIN I Y <br /> ENVIRONMENTAL Hr '.TH DEPARTMENT Return th* rm <br /> � the 12 of�—ch n <br /> y 600 East Main Street, S ton,CA 95202-2708 to <br /> Telephone:(209)468-3420 Fav(209)464-0138 Web:www.sjgov.org/ehd <br /> C�gClFO,R��P CHEMICAL TOILET CLEANERS REPORT <br /> Company Name: � ,� 'S Report for the month of. year_ <br /> Company Address: 9 e;?w Signature: <br /> Street Address City Zip Code <br /> All information submitted must be complete, accurate, and legible <br /> DATE TOTAL NUMBER OF TOTAL VOLUME OF <br /> CITY WHERE PUMPED CHEMICAL CHEMICAL 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 DISPOSEI <br /> CITY PER DATE <br /> 41 9 • 36 - ; 0 ,ll weAm-- !&epo loins '5eAved 1 .r ?'w "V4wla <br /> S-2-2--'q " <br /> -2—1 tgcEiez indvnik 3 <br /> 6-s- 141 , t <br /> - - 1 <br /> DdIA2 <br /> P.,! � l cKe q6 <br /> 9 -Z.4- I q le-, � <br /> EIID 42-017 Chemical Toilet Report <br /> 9/23/2004 <br />