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CERTIFICATE OF ®ISPOS/ URECYCLING <br /> San Joaquin CountyRegionai HousehofdHazardous U'Vastfe program <br /> San Joaquin County Household Hazardous Waste Facility :;\ <br /> 7850 South R. A Bridgeford Street, Stockton, CA 95206 F1 � :�� ; 1 <br /> Administrative Office: (209) 468-30616 r : <br /> Customer Information <br /> Name (print) <br /> � Bate - <br /> ) <br /> stmet Address -- -- <br /> _ / 7 <br /> C; diylsfatelrifr Cade - --- - — - _ - �4rea M& S Tefephona tatumber - <br /> I declare, uRdea penalty citolry, #ttat:€dte,t esia t �Customer SIgma$re � <br /> brought to this MCI* was generated by a resident and f A ;" <br /> was not generated by a . business, / y <br /> Mat <br /> WaPrncessetE <br /> 40 , <br /> r <br /> `/ mit s <br /> � / <br /> ! kB t 7 er-%Z` s <br /> • a <br /> . 7d i <br /> TO be campfatfty H14W Facility SfaffMN mw <br /> The San Joaquin County :Household .#jaZW'doUS WasteFEadlityt ceytfflft ;accepftanceOf1he <br /> material referenced on this ,docurnent. The material has been managed in accordance <br /> -with Untied States Enviflonrnental Protect•ion Agency and State of Caltifomia Environmental <br /> Protection Agency waste management regulations . <br /> Staff Vembar Signaturev <br /> Staff Member Name tint):. 'e' <br /> Environmental Health Referrat . Y • <br /> 1 chide license Pate naagw C2l Qi � ' <br /> r <br />