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SAN JOAQUIN COUNTY <br /> .z• ENVIRONMENTALTH DEPARTMENT Return thi m by <br /> to 600 East Main Street,Slwn,CA 95202-2708 the 12th ofw month <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> CHEMICAL TOILET CLEANERS REPORT <br /> Company Name: cc s Report for the month of: year <br /> Company Address: ZZ Signature: <br /> Street Address City Zip Code <br /> All information submitted must be complete, accurate, and legible <br /> TOTAL NUMBER OF TOTAL VOLUME OF <br /> DATE 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 DISPOSED <br /> CITY PER DATE <br /> -t-� 6 - I <br /> "Timms _ /4 �A&A- <br /> �� C'0t(9- <br /> c' <br /> U,o lat <br /> in vz <br /> A'-� <br /> IC <br /> YN <br /> e 4e <br /> ---� �D Q1Z� f'e z e Cf X-e�wrc ' e all Ze .� <br /> 5- /-14 9 - so--14 �. G28 �N s Sa®w l '&WIC el :n,021,r a <br /> EHD 42-017 Chemical Toilet Report <br /> 9/23/2004 <br />