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FN. <br /> a5r <br /> N <br /> _ = <br /> f�i <br /> CERTIFICATE OF DISPOSAURECYCLING ?"i1 i, ? 2017 <br /> ENVIRONI, NT <br /> San Joaquin County Regional Household Hazardous Waste Program PERM;r . ALN SLTH <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 /> R. <br /> Customer Information <br /> Name(print) <br /> Date- <br /> FAddressde Area Code&Telephone Number <br /> � Cid � 1c � � � b6Zder penalty of perjury, that the waste I Customer Si atufacility was generated by a resident and not generated by a business. <br /> Material Received Quantity (lb/gal) Date Processed <br /> 3 -,-2 —> <br /> --------------------------------------------------------------•------ -------- --------------------•--•----------- <br /> To be completed by HH W Facility staff Member <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 /> Staff Member Signature: <br /> �y f <br /> Staff Member Name(print): <br /> Environmental Health Referral: Y N <br /> Vehicle License Plate Number(if applicable): <br />