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einnlit Oki*, Dab Processed Pifidoriet Received <br />nature: Staff Member SI <br />Staff Member Name <br />CERTIFICATE OF DISPOSAURECYCLING <br />San Joaquin County'Regionall Household Hazordeue N7siata Program <br />San Joaquin County Household Hazardous Waste Fealty <br />7850 South R. A Bridgeford Street, Stockton, CA 95206 <br />Administrative Office: (209) 468-3066 <br />Customer information <br /> <br />Name (print) <br />r- . <br />L,GOlivr10/1 1)1c-,-- <br />o6) la <br />A445„. +(i- 9 -IG —)IStreet _12714v)p <br />Dab <br />Address <br />1:7 r,2,)1(c,:d, a();,1--.‹ I _1. p Code <br />cil- qs----)(q <br />Ana* Code IMISPhons Number <br />(20 \510--ncig <br />/declare, under penalty of peOry, that the waste I <br />brought to this AtcaNty wes genet/Mad by a resident and <br />was not generated by a busines& <br />G Signature <br />j r 1,--r ---- <br />To be comorsisi by FM Fedlity 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.