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Yehicle License Plate Number if applicable <br />Staff Member S nature: <br />Staff Member Name (print <br />Environmental Health Refetral: • <br />• <br />COM-MATE OF DiSPOSAURECYCLOW <br />San Joaquin C©ufity Regkod Gloana@hm Hauwagrio mut <br />San Joaquin County Household Hazardous Waste Facility <br />7850 South R. A Bridgeford Street, Stockton, CA 95206 <br />Administrative Office: (209) 468-3 <br />Customer information <br />PINVOMPTIV <br />Name (print) <br />bckoal (bcd otk_ Street Address <br />5v:1- (-1/1 <br />Dale <br />7 <br />-Coda <br />5)-,6 <br />I dam, under penalty of perjury, that the waste i broug)t -to this feality was generated by rasideree end <br />was not generated by a business. <br />• <br />5 <br />A'tiagiZade 8•146filiFions flfearther <br />VO/ <br />Cuslogrier Signature <br />To be op1etethy 1041N Faellty Staff gember <br />CrtAfcatbon Sitatesseirek <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 wasp management regulations.