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` ENVIRONMENTAL HEALTH DEPARTMENI Return thi: <br /> 11�t :moi 600 East Main Street,Stockton,CA 95202-2708 the 12"' oS <br /> ..�.t i Telephone:(209)468-:420 Fax:(209)464-0138 Web:www.sjgov.org/eixi <br /> CHEMICAL TOILET CLEANERS REPORT <br /> Company Name: '' Report for the month of: <br /> Company Address: Signature: _ <br /> Sheet 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 TOILETS CIIEMICAL TOILET WASTE NAME OF TREATMENT FACILI I <br /> PUMPED TOILETS ARE LOCATED PUMPED IN SPECIFIED PUMPED PER CITY PER DATE WHERE CHEMICAL TOILET WASTE I}l <br /> CITY PER DATE <br /> f .3f4 <br /> �T gJG 'ez"L r. rY/'r <br /> Al .. <br /> / . <br /> f ei <br /> ZI <br /> f <br /> r <br /> f 1 X7r� <br /> i/ <br /> j <br /> EHD 42-017 Chemical To l„ <br /> 9;23!2004 <br />