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CERTIF'ICA'TE OF D1SPOSAURECYCLI�CEIVED <br /> Joaquin Cou R "�� 6 S 2016 <br /> San dos <br /> 4 my Regional Household Hazardous Waste grog <br /> San Joaquin County Household Hazardous Waste Facility RON 4E � tT. <br /> 7850 South R.A Bridgeford Street, Stockton, CA 95206 PERMIT �Rv;C S <br /> Administrative Office: (209)468-306651 <br /> Customer Information <br /> Name(print) <br /> n Date <br /> StreetAddress M ��/C. O <br /> VV <br /> CltylState0p Cadet' n Area Code&Telephone Number <br /> ✓ <br /> /declare, underpenalty of perjury,that the waste I Customer Signature <br /> brought to this facility was generated by a resident and <br /> was not generated by a business. <br /> Matorial Received Quantity (Ib/ al <br /> 8 ) Date Processed <br /> /A- 10 f!„ <br /> Ll <br /> ••---•-- <br /> ------------------------------- <br /> To be completed by HHW Facility SUR AAemher <br /> Certification Statement: <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 /> i <br /> Staff Member Signature: <br /> [EEnvironmenital <br /> taff Member Name(print): � r L� <br /> Health Referral: N <br /> nse Plata Number(if a plicable): L C.7 L �' <br />