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ce ENVIRONNI NTAL HEALTH DEPARTMENT / Return this form by <br /> { 600 East Main Street, Stockton,CA 95202-2708 the 12t1' of each month <br /> Telephone: (209)468-3420 Far.(209)464-0138 Web:www.sjgov.or� <br /> CHEMICAL TOILET CLEANERS REPORT _ <br /> Company Name: j,�.t; �rl_2.. Report for the month'o#-' `-� year <br /> Y <br /> p r-. • ... ( rte Signatu'r'Vet��)N�EN'r <br /> Company Address: r��` = „' - <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 TOILETSCHEMICAL TOILET WASTE NAME OF TREAT HENT PACILITY <br /> PUMPED TOILETS ARE LOCATED PUMPED IN SPECIFIED PUMPED PER CITY PER DATE µHERE CIiE1flCAI TOILET WASTE DISPOSED <br /> CITY PER DATE // <br /> r r <br /> iS <br /> o <br /> f <br /> l` <br /> 411 <br /> ( LC 2 -1 <br /> .7 <br /> -r:,;: <br /> 1 ' €' <br /> Chemical Toilet Rcxrl <br /> EH D 42-017 <br /> 9123/2044 <br />