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a <br /> �o co JAN JOAQUIN COUNTY <br /> = ENVIRONMENTAL HF—v DEPARTMENT 1 Return this ` m by <br /> wlovw� <br /> 600 East Main Street,St, bn,CA 95202-2708 the 12`�of, � month <br /> Telephone.(209)468-3420 Fox:(209)464-0138 Web:www.sjgov.org/ehd <br /> CHEMICAL TOILET CLEANERS REPORT <br /> Company Name: sem" C �S Report for the month of: year <br /> Company Address: Signature: <br /> Street Address City Zip Code <br /> All information submitted must be complete, ace rate, and legible <br /> TOTAL NUMBER OF TOTAL VOLUME OF <br /> DATE CITY WHERE PUMPED CHEMICAL CHEMICAL TOILETS CHEMICAL TOILET WASTE NAME OF TREATMENT FACILITY <br /> PUMPED TOILETS ARE LOCATED PUMPED IN SPECIFIED PUMPED PER CITY PER DATE WHERE CHE?I ICAL TOILET WASTE DISPOSED <br /> CITY PER DATE <br /> 2-to-12 I,-w RI(o-$l2-$33�" k�iK <br /> 2-�-Ii- Cd btl�c.ef-s r,H <br /> 2'!•o-1Z AAy D/SG6V tE A 1Oc) <br /> Z-Cr-IL ,� 2tv G Y-)40, <br /> 2 16-12- PaeoN = lel- Cl 001 -31"1-10 too I<I14 S <br /> 16-)7- RoN - 5501 -731-05%0 e <br /> 2- 13-12 Tit,hu,¢,Q- a ns�l sa 510- 10653 V-W 1 41 <br /> 2w KI JS <br /> V-12-1V- -3 a V -w <br /> -15—► aM I� S aG0 V-1 n/ S <br /> s kA Kl <br /> 14 �- l+ 2U0 ,t <br /> �-as- t2 - ?Qt,tWS too <br /> 12 V-w M- lS tore V-w <br /> L- 12- klINA.5 — 5- btSCL tom KIN S <br /> .5- 12,-12 DOLK, 1.60 V -ta7 <br /> 3-12-1E 4 - us- a i aLS 4bo V - � <br /> 3- q- i 2 c_ 91(6-842 -z44191, 240 v <br /> 5&eu L forts Kt S <br /> EHD 42-017 Chemical Toilet Repots <br /> 9232004 <br />