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OFIMMOM UPRE'MCUM <br /> Son Joaquin County'Reglapao Houo(3hood m&RmK&Q)u0 N7n.%&-pq0@jmm <br /> San Joaquin County Household Hazardoue,Wmate Fac flity <br /> 'A <br /> 7850 South R.A Bridgefbrd Street, Stockton, C 95208 <br /> Administrative Office:(209)468-3066 <br /> customer Information <br /> Name(print) Date <br /> S'JC Ricky Lc)-P&-Z- -';2 <br /> Stfoot Address <br /> OtyxiefAMP-Cods Teko—pane Numb-or <br /> I declare under penalty orpeguty that the Waste I CUMMUT'SID"tM <br /> brought to this fmft was generated by a§6-8?d2Vd and <br /> was not generated by a business. <br /> La, <br /> S-C' 3 <br /> -2-,)-,3 <br /> ................................................. ............. ..................... ............. ...... <br /> To be Nhw r-&4itKy stat membej, <br /> Certification SUtem@ni.- <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 /> wfth United States Envimnmental Protection Agency and State of California Environmental <br /> Protection Agency waste management regulations. <br /> Staff Member Softre. <br /> Staff Member Name(print): -D-LJ-t e- <br /> =n 8891%Referral:. Y <br /> nee Phft Number if ap <br /> L* bjj9! IU[A <br />