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R <br /> CERTIFICATE OF DISPOSAL/ <br /> W W76--1 <br /> San Joaquin County Regional Household Hazardous Wast&Jgiamrs <br /> San Joaquin County Household Hazardous Waste Facility <br /> 7850 South R.A Bridgeford Street, Stockton, CA 95206 <br /> Administrative Office: (209)468-3066 <br /> customer Information <br /> Name(print) <br /> Data <br /> q �J > <br /> 7Street Address �� c1//✓`J d-�e�'y� O <br /> Cltyf9tate2ip Codec Area Code&Telephone Number r <br /> I declare, under penalty of perjury, that the was I Customer Signature <br /> brought to this facility was generated by a resident and <br /> was not generated by a business. <br /> 276o <br /> Material Received �� / <br /> Quantity (lb/gal) Date Processed <br /> ------------------------------------- _ <br /> ----mbeT -----------------rtht�ffp�'r27 p <br /> To be Completee 6y HHW Facility Staff Memher I1UU G J �'..1�^�...... <br /> Certification Statement: ^ Joe. <br /> 3 11 <br /> The San Joaquin County Household Hazardous Waste Facility certifies acceptance of the <br /> material referenced on this document. The material has been managed in accordance <br /> with United States Environmental Protection Agency and State of California Environmental <br /> Protection Agency waste management regulations. <br /> Staff Member Signature: <br /> Staff Member Name( rint): <br /> Environmental Health Referral: N <br /> Vehicle License Plate Number(if applicable): <br />