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CERTIFICATE OF DISPOSAURECYCLING FNV UAf 13 2016 <br /> fRo,% <br /> San Joaquin County Regional Household Hazardous Waste Program pF FN>�H Ty <br /> San Joaquin County Household Hazardous Waste Facility CFS <br /> 7850 South R. A Bridgeford Street, Stockton, CA 95206 <br /> Administrative Office: (209)468-3066 '. I ' <br /> Customer information <br /> Name(print) <br /> / Dale <br /> �t'M6}o �c r�nr✓rs 1—L �o /bl/ <br /> Street Address <br /> e�� 9 kt LJ <br /> CItyl8tate2lp Code Area Code&Telephone Number <br /> I declare, under penalty of perjury, that the waste I Custom Ignature -rllornas \ Ia n q <br /> brought to this facility was generated by a resident and v <br /> was not generated by a business. <br /> Malarial Received Quantity (lb/gal) Date Processed <br /> To M gmp!efid t'Y HHw FaC::ry 51aA,Hiember <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- nyin r <br /> - --o - - <br /> -- Telephone(209)468-3066 <br /> r— <br /> E-mail:ojanvrin@Vgovorg <br /> Staff Member Signature ��,,-� - FAX(209)468-5672 <br /> Staff Member Name(print): V, n <br /> OLLIE JANVRIN <br /> Environmental Health Referral: Y• N HIM Operations Coordinator <br /> Solid Waste Division <br /> 81 <br /> 1810 <br /> Vehicle license Plate Number if a plicable: 181 <br /> Bax <br /> 7810 E. Hazelton Avenue <br /> .Stockton, Calffomia 95201 wrvw.sJ90r.or91soliduwste <br />