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ENVIRONMENTAL HE '-"'t DEPARTMENT (� 1 Return this(' by <br /> v Is <br /> rA 600 East Main Street,St CA 95202-2708 the 12'"of a honth <br /> 7-4 —o')ATelephone:(209)468.3420 Fax:(209)464-0138 Web:www,sjgov.org/ehd <br /> :m�. CHEMICAL TOILET CLEANERS REPORT <br /> FO <br /> Company Name: Report for the month of: year <br /> Company Address: Signature: <br /> Street Address Cily Zip Code <br /> ,il Information submitted must be complete. see u rate, and legible <br /> TOTAL NUMBER OF TOTAL VOLUME OF <br /> DATE CITY WHERE PUMPED CHEMICAL CHEMICAL TOILETS CHEMICALTOILETWASTE NAME OF TREATMENT FACILITY <br /> PUMPED TOILETS ARE LOCATED PUMPED IN SPECIFIED <br /> CITY PER DATE PUMPED PER CITY PER DATE WHERE CHEMICAL TOILET WASTE DISPOSED <br /> n r <br /> .50 " — P3 <br /> 5�I2 i V-kJ .5'0 <br /> mKt4tA <br /> - 12 S' I, n TLS <br /> -I2. V- JLV3 50 <br /> E -Qs <br /> 4w <br /> W <br /> 1 — <br /> _ 4 — <br /> a LA . v1 <br /> -0 <br /> to <br /> —15 IZ t <br /> - 4- <br /> _561 <br /> :HD 42-017 Chemical Toilet Repo" <br /> )/232004 <br />