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CillFt OF DISPOSALRECIFCLING <br />San J4in County Mi:lional Household WIREMOUB neSil.12 Progra <br />San Joaquin County Household Hazardous Waste Facility <br />7850 South R. A Bridgeford Street, Stockton, CA 95208 <br />Administrative Office: (209) 468-3066 <br />Customer inibmudiu4 <br />name (print)Date <br /> <br />i f , <br />\ ,._-• e e 1 0/116/T c1/--c ) a <br />Street Address <br />/33 1 5 k(ivift Las) • <br />CityfabdviZip•Oode <br />Ladi cA\ <br />A'rei Code & Telephone Number <br />I declare, nder penalty of perjury, that the waste I <br />brought to -this facility was generated by a resident and <br />was not not generated by a business. <br />Customer nature • <br />IltateNaf Received CMostity ( lb I Elek)• Dalt Processed <br />A/CRT=7)/°- ,‘•-/ r-.(10.5# ''Z4‘'-' 61 ,* . L._ / c•--.:), 7.1 <br />5, -') / / 7e la.-,26 ?%),c4,e,- Adi--- f-2, <br />To be comptated by 1-111W FatItty 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: k .4,14-. <br />Staff Member Name (print): Al /11X.'-• /,,, / A )/6,,/,/ <br />Environmental Health Referral:. V• N <br />yehicle License Plate Number (if applicable): . -