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ENVIRONMENTAL HEP' T DEPARTMENT Return this(' � by <br /> 600 East Main Street,Std CA 95202-2708 the 121h of e:. Month <br /> i. Telephone:(209)468-3420 Fax:(209)464-0138 Web:wwwsjgov.org/ehd <br /> �<ci O ;0, CHEMICAL TOILET CLEANERS REPORT <br /> Company Name: �� �L'r Report for the month of: year <br /> Company Address: Signature: <br /> Street Address City Zip Codc <br /> ,II Information submitted must be Complete, seen rate, and leigible <br /> TOTALNUMBEROF 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 CHEMICAL TOILET WASTE DISPOSED <br /> CITY PER DATE <br /> - 1 <br /> Ng1� <br /> a T— <br /> C <br /> S� <br /> (Aht-i t0L) 110 MAL- <br /> I <br /> IL <br /> 5" 0- Eel!) <br /> (1-c9!L ICS <br /> �. <br /> 'HD 42-017 Chemical Toilet Repo" <br /> 12312004 <br />