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ENVIRONMENTAL HE '—" DEPARTMENT Return this �}by <br /> t 600 East Main Street,Std CA 95202-2708 the 12"' of e�" hgnth <br /> Telephone:(209)468-3420 Fox:(209)464-0138 Web:www.sjgov.org/ehd <br /> CHEMICAL TOILET CLEANERS REPORT <br /> Company Name: <C r l/(nE Report for the month of: year <br /> Company Address: Signature: <br /> Street Address City Zip Code <br /> .ii Inrormation submitted must be complete. accurate and le Ible <br /> TOTAL NUMBER OF TOTAL VOLUMEOF <br /> DATE CITY WHERE PUMPED CHEMICAL CHEMICALTOILETS CHEMICAL TOILET WASTE NAME OF TREATMENT FACILITY <br /> PUMPED TOILETS ARE LOCATED PUMPED IN SPECIFIED PUMPED PER CITY PER DATE WHERE CHEMICAL TOILET WASTE DISPOSED <br /> CITY PER DATE <br /> I5=1' _(v7 Pas <br /> -1- , 1,16 <br /> 15-i2 an oa- <br /> -Is - I S 160 <br /> -lS- v - w <br /> i.S-I - w <br /> E ! 03zul� <br /> 0,010M 1) 1 NO ji�njiRr)�wFKITAI HEALTH <br /> 2W PERMITISERVICES <br /> ftVOP LII t <br /> C <br /> tS _W (� <br /> 1(4 <br /> s z Ahn <br /> ZHD 42-017 <br /> t/23/2004 Chemical Toilet Report <br />