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SAN JOAQUIN COUNTY <br /> oo ENVIRONMENTAL HF TH DEPARTMENT Return thi• m by <br /> m 600 East Main Street,S. Ion,CA 95202-2708 the 12th of � month <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> 1, - CH- 3t4-*" <br /> , jy�,CHEMICAL TOILET CLEANERS REPORT u <br /> Company Name: �y Xj0)16- �/t4" � - ',tri Report for the onth of: /� -I/ �r yeafr —/ , �- <br /> Company Address: % .Sur/ Signature. l+� M <br /> Street Address City Zip Code <br /> All information submitted must be complete, accurate, and legible <br /> TOTAL NUMBER OF 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 /> -D OD o -W <br /> 40- // S l'// &11e .vS U 'I.t1 <br /> SD -IW <br /> /SD I/-6d <br /> T - <br /> l -�Z e m1t- �cvicer8 l !G <br /> SZ) 'Al•AlIff <br /> -FZMAI - CAA& <br /> )L AI <br /> l -127vy W4,Aw _ am mq <br /> ^8 f .taut W&VAPa4 0QV - <br /> / ,5 0* N o?1.1D <br /> z-W Ari 0., <br /> Ste. -./7 l04 120 s <br /> l-ZA-! <br /> l2 d)�& 64eves S <br /> EHD 42-017 Chemical Toilet Repon <br /> 9WC004 <br />