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ENVIRONMENTAL HES`' t DEPARTMENT Q <br /> d Return this ', 'I by <br /> 600 East Main Street,St ,CA 95202-2708 the 12th of e�� Aonth <br /> k :x. Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> V. <br /> Po' CHEMICAL TOILET CLEANERS REPORT <br /> Company Name: :�'� P&j Report for the month of: year <br /> Company Address: Signature: <br /> Street Address City Zip Code <br /> Al information submitted must be complete, accurate, 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 /> /D -iG-%3 2��ti5v s O <br /> lei/I <br /> /ZkO <br /> 7,/ <br /> 66) <br /> le) -22-/3 au wcu SO <br /> 40 <br /> Szc4c2�. 1CrD <br /> // /.3 uctrCJ <br /> i <br /> ,IY21WI19, S%ai24t7M S4 Sd <br /> I <br /> 'HD 42-017 <br /> Q3/2004 Chemical Toilet Report <br />