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SAN JOAQUIN COUNTY AGRICULTURAL COMMISSIONER'S OFFICE <br /> PESTICIDE CONTAINER RINSE SELF-CERTIFICATION <br /> PLEASE TAKE NOTE: THIS SELF-CERTIFICATION FORM IS VALID ONLY FOR SCHEDULED <br /> PESTICIDE CONTAINER RECYCLING DAYS. Pesticide containers delivered to a landfill on a day that is <br /> not scheduled for recycling must be inspected by the Agricultural Commissioner's Office before delivery. <br /> Name: (print): AZ <br /> r <br /> Company: C <br /> Vehicle License No(s): / Z b D / o <br /> Delivery Date: Number of Containers: 3c, *k <br /> y <br /> O <br /> CJ7 <br /> Recycling Site (circle): North County / Lovelac / Tracy R' <br /> 0 <br /> v <br /> I hereby certify that this load of pesticide containers has been triple rinsed or continuously rinsed in <br /> accordance with S ction 6684, �}f the Crnia Code of Regulations.The containers are also punctured <br /> at both ends. 'J a'/ <br /> u <br /> Signature: �. -�/ Date: <br /> Original:Person in Possession <br /> Copy: Landfill Operator/Agricultural Commissioner 612012 m <br /> Z rn <br /> 00 C <br /> Z ~ <br /> CD � <br /> rn N <br /> 0 <br /> Zi = �' <br /> M <br /> D <br /> rl <br />