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R u co SAN-JOAQUIN COUNTY <br /> � <br /> �fV1RONMENTAL HEALTH DEPARTMEN€ Return this form by <br /> CD 304 East Weber Avenue, 3r4 Floor,Stockton,CA 95202-2748 the 121> of each month <br /> w Telephone:(209)468-3420FiL:(209)464-0338 Web: kvww.sjgov.org! ENTER <br /> n <br /> fi CHEMICAL TOILET CLEANERS REPORT <br /> CD Company Name: j- T // {h. S _ Report for the month of: year 4 _ <br /> w Company Address: lam' kj_ Signature: <br /> N <br /> street Address Oily Zip Code <br /> E_l_ T;II informattan Sub mittcd must be complete, accurate and legible <br /> TOTAL NUMBER OF TOTAL VOLUME OF <br /> DATE CITY WHERE PLth1PED CHEMICAL C1101ICA L TOILETS CHEMICAL TO[LET WASTE NKA ME OF TREATMENT FACILITY <br /> PUMPED TOILETS ARE LOCATED PUMPED IN SPEC IFTED PV.4IPED PER CITY PER DATE 'WHERE CHEMICAL TOILET WASTE DISPOSED <br /> CITY PER DATE <br /> 00 <br /> ?d P 223 <br /> Q lEM P D-a) .35 ItLn <br /> Cn <br /> M >� c T A- <br /> O 4 <br /> .Ln <br /> 1 Mw Rai <br /> ft Mal <br /> 5-c) ' <br /> 1. 0 <br /> DO <br /> m.. <br /> lctlt?d i}t7 <br /> * Chemical Toilet Repari <br />