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Staff Member Signature: <br />Staff Member Name (print: <br />Environmental Health Referral: <br />/Vehicle License Plate Number (if apphesiole): <br />CERTOFOCATE OF DISPOSALMIECYCLUNG <br />San Joaquin Comfit), Regional) IN Hata-Mom Mote Peognett <br />San Joaquin County Household Hazardous Waste Facility <br />7850 South R. A Bridgeford Street, Stockton, CA 95206 <br />Administrative Office: (209) 488-3066 <br />Customer Information <br />Name (print) <br />cTble., 141,c,inn <br />DAS <br />1 012 1-I2-0.2-1 <br />Streit Address <br />%Om. 5 L OLLricOt <br />CItylStaireafp-Code <br />\-°a•-i CIA ct s2.-i 2_ 1 . <br />AulagiOrlde 8 Tefopilon Nowther <br />2ocl . Let,2-2.) . ool .(7 <br />I declare, under penalty of perjury, that the waste I <br />brought to this faculty was generated by a residant end <br />was not generated by a business. <br />custom Signature <br />lobe complete4. by NM Facility Staff Member t. <br />Certification Statertiwai: <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.