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ENVIRONMENTAL HE 1 DEPARTMENT Return this! }by <br /> t 600 East Main Street,Std CA 95202-2708 the 12'h of a honth <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sigov.org/ehd <br /> �gCIF Ow;v�? CHEMICAL TOILET CLEANERS REPORT <br /> Company Name: Report for the month of: year <br /> Company Address: Signature: <br /> Street Address cilY Zip case <br /> ,II Information submitted must be complete, accurate, and legible <br /> TOTALNUMBEROF TOTAL VOLUME OF <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 /> 6-lc- ,2 :. <br /> d <br /> e <br /> 0 <br /> if 02S <br /> - r 'T f". <br /> - b �- <br /> t _ , <br /> =! <br /> C-19 <br /> v -w �fv,s tcf <br /> a <br /> � Q i <br /> IZ - - 6J <br /> t " ,.•G <br /> to <br /> - 6l.! <br /> ND 42-017 <br /> Chemical ToiWt Report <br /> IR3R004 <br />