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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Return this form 1b <br /> r 304 East Weber Avenue, 3Td Floor,Stockton,CA 95202-2 � � the 12`e of each M*Rth <br /> Telephone:(209)469-3420 Fax:(209)464-0138 Web:www.sjgov.o d <br /> v CHEMICAL ET CLEANERS REPORT m <br /> Company Name: Jr � COILReport for the month of: year _ <br /> Company Address; f1 s 15;10(o Signature: r m <br /> ueel Address City Zip Code <br /> - cn <br /> All information submitted must be complete, accurate and legible <br /> TOTAL NUMBER OF <br /> TOTAL VOLUME OF <br /> DATE CITY WHERE PUMPED CHEMICAL CUEhIICALTOILETS NAME OF TREATMENT FACILITY O <br /> PUMPED TOILETS ARE LOCATED PUMPED IN SPECIFIED CHEMICAL TOILET WASTE WHERE CHEMICAL TOILET WASTE DISPOSED 3 <br /> CYI Y PER DATE PUMPED PER CITY PER DATE H <br /> rr G] <br /> .e <br /> 35 <br /> QA- <br /> 60 <br /> O <br /> w <br /> _ 3p_a <br /> roed <br /> 0-t2o <br /> �-- -f.3► <br /> `� C&V%& C) <br /> (. .? t -6 --?-D <br /> -! 3 -b <br /> e>9. 'ort GA, I ' a <br /> - ro <br /> m <br /> r <br /> N <br /> t W <br /> S 'a <br /> EBD 42-017 Chemical Toilet.It wf <br /> 9rL=04 `x <br />