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Working for YOU <br /> San Joaquin County Household Hazardous Waste Facility <br /> 1 Date: r <br /> 2� 200 , <br /> 2. Name: <br /> Address: YY1tf1 ' <br /> Cit : Zl . <br /> 3. Inside City Limits Outside City Limits (check one) <br /> I hereby swear that the waste I am deliverying today was generated in San Joaqin County by a <br /> residence and not in a business endevor. Business waste is a waste generated in the course of <br /> 4. doing busine s, even if that usiness is operated out of your home. Business waste also includes <br /> waste generat d by c urche , schools ent agencies, non:profits, property management or <br /> apartm g ent, f profit ranc es and farms and stroage companies. <br /> Si ature: <br /> 5. I am lieverin aste from # L households today. 5 ( S <br /> 6. I have use a Ho Hazard us waste Collection Facility# <br /> 7 1 heard about this program through the f Ing: (circle all that apply) <br /> �. LHazardous <br /> d ^�Was , Q4 a <br /> Recycling Guide/ <br /> Phone Book Website <br /> Flyer/Mailer <br /> Newspaper Ad/Article Called Solid Waste <br /> name 468-3066 <br /> Other: <br /> (describe) <br /> Word of Mouth <br /> Official Use Onl �a <br />