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ENVIRONMENTAL HE • �.,DEPARTMENT Return this by <br /> e" Fir 600 East Main Street, SY ,CA 95202-2708 � the 12th of C tonth <br /> „�°� • t. Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> O CHEMICAL TOILET CLEANERS REPORT <br /> Company Name: cS Report for the month of: year <br /> Company Address: Signature: <br /> Street Address City Zip Code <br /> Al information submitted must be com letc see rate. and legible <br /> DATE CITY WHERE PUMPED CHEMICAL TOTAL NUMBER OF TOTAL VOLUME OFCHEMICAL 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 /> /2 <br /> i2 -2a-'=y i,'x rL /coo <br /> Ai <br /> It)4t a>✓� Sd <br /> "74 r.2 <br /> . 350 <br /> N a <br /> iL"is fi � --� w .�7Q7`� 0L 8l� <br /> mk e- <br /> MAs <br /> -HD 42-017 <br /> 1/23/2004 iChcmical Toilet Report <br />