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1h SAN JOAQUIN COUNTY <br /> ENVIRONMEN'T'AL HEALTH DEPARTMENT Return this form by <br /> 304 East Weber Avenue, Yd Floor,Stockton,CA 95202-2708 the 12th of each month <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web,www.sjgov.org/ehd � <br /> CHEMICAL TOILET CLEANERS REPORT Do <br /> rj <br /> to <br /> Company Name; �1.4c j e� � .5- Repan for the nonth of: year <br /> Company Address: Ct' 'e C (!*j 6(n Signature; <br /> Sheet Address City Zap Cade <br /> All information submitted must be rom Tete, accurate, and legible 0) <br /> TOTAL NUMBER OF TOTAL VOLUME OF � <br /> GATE CTTY WHERE PUMPED CHEMICAL CHEMICAL TOILETS NAME OF TREATMENT FACILITY o <br /> 3 <br /> PUMPED TOILETS ARE LOCATED PUMPED IN SPECIFIED CHEMICAL TOILET WASTE PUMPED PER CrrY PER DATE WHERE CHEMICAL TOILET WASTE DISPOSED <br /> .L CITY PER DATE � <br /> --Est" Pesov-� (54-oe-kj— <br /> Ln <br /> r <br /> Ln <br /> CDy <br /> y.. -t cn <br /> ` S 1 Er t4 j c .ice c �° <br /> C11 <br /> :2D ' <br /> 00 <br /> F <br /> i <br /> CD <br /> W <br /> "ty <br /> @ <br /> CM <br /> [U <br /> W <br /> W <br /> M <br /> N <br /> EKD 42.617 <br /> amnnnd Chemical Toilet Report <br />