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SAN JOAQUIN COUNTY <br /> RECay <br /> ENVIRONMHNTAL HEALTH DEPARTMENT JUN 0 5 2009 Return this form by <br /> CD 304 East Weber Avenue,3d Floor,Stockton,CA 95202-2708 the 1P of each mouth <br /> cli <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgovmg/ehdENVjR0NMENTHE A <br /> � P CHEMICAL TOILET CLEANERS REPORT <br /> PERMIT/SFRVIG <br /> ENTERED <br /> @ n <br /> N Compgny Name: � 1 uc IBJ _ Report for he m nth of: year <br /> Company Address; ����A CJ!S Signature: <br /> Stsw ares; Cir, Zip c, <br /> L All Information submitted must be complete, accurate, and le ible <br /> S TOTAL NUMBER OF TOTAL VOLUME OF <br /> DATE CITY WHERE PUMPED CHEMICAL CHEMICAL TOILM CHEMICAL TOILET WASTE NAME OF TREATMENT I<ACILi'7.`Y <br /> PUMPED TOILETS ARE LOCATED PUMPED IN SPLCIFIED PUMPED PER CITY PER DATE 1YHERE CHEMICAL TOILET WASTE DISPOSED <br /> CITY PER DATE <br /> CF) ho 125 2nA <br /> Rks 13,ic an o5 <br /> i t <br /> r � 4 ' TAV <br /> A'rSLOAN � � +5r <br /> 5 <br /> A- <br /> E- <br /> 0 <br /> -H <br /> -ByC�sn l —r,UU <br /> too 'eH <br /> w i �fCD <br /> � `� <br /> oo <br /> �3 e, <br /> CD 3 30 <br /> q'V.Ew 42-011 Chemical Toil!Report <br /> 9/1312004 <br />