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a <br /> NECJ�f , <br /> ?aa°te t=N'.cG SAN 3v.�.QULN COUNTY <br /> EI V E® . <br /> r\ T� Return this fort by <br /> c 304 Last Weber?.venlue, �`° Baer, StociaQ i C. � � ��� � � 20 1 the I2'h of each month. � <br /> . a Telephone:(209)46$-3=2-0 Fax: (2-091464-0138 <br /> CHEMICAL TOILET CLEANTRS REPORTENVIRONMENTAL HEALTH <br /> PERMIT/SERVICES <br /> Compan Name: , 5 Report for th month of. 3 tiear <br /> Company Address; J� C} [.J. J�" Sig�att3ire: � <br /> Ali information sub-misted must, be corn lete. accurate. and legible O <br /> TOTAL S V NIBER OF <br /> TOTAL VOLUME—OF � <br /> DATE CITY RHERE PUMPED CHEMICAL CHEMIC.aL TOILETS i CHEM]CAL TOILETIl � NAME OF TREATMENT FACILITY ti <br /> PUMPED TOILETS ARE LOCATED PUMPED IN SPECIFIED E � WHERE.CIiEti7IC.4L TOILET"WASTE DISPOSED � <br /> CETT"PER DATE I PL�fPED PER CITY PER DATE � <br /> Ln <br /> 1-5 <br /> ✓> h fir) , <br /> o �s a • <br /> � d <br /> _--- 0 <br /> err ar7 n -3 <br /> �.. <br /> �// ✓ers 3S 1 `n f'rn <br /> CAL <br /> GD <br /> iG <br /> to <br /> LT, <br /> Cl i ti�w J oma. .. S I <br /> for ' <br /> ~ s e <br /> w <br /> m <br /> / <br /> 400 <br /> 2- � o d; e a <br /> M <br /> All l <br />