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a <br /> Working for YOU <br /> San Joaquin County nHousehold Hazardous Waste Facility <br /> 1 Date: 6U ii�o `01b <br /> 2. Name: j ` .2� <br /> Address: <br /> City:z�i ` `� Zip:�S2 S <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 business, even if that business is operated out of your home, Business waste also includes <br /> waste generate by ch rches, ools, government agencies, non-profits, property management or <br /> apartment com ex ma�nageme t, for profs ran es and farms and stroage companies. <br /> CSignature: , <br /> 5. 1 am delivering v aste households today. <br /> 6. 1 have ustd t�Household-Hazardous waste Collection Facility # <br /> 7 1 heard about this program through the following: (circle all that apply) <br /> Household <br /> n,prvu, <br /> Hazardous Waste - <br /> `r'e Brochure <br /> Recycling Guide/ " <br /> Phone Book -- Websit <br /> r <br /> / <br /> I/ Flyer/Mailer <br /> Newspaper Ad/Article Called Solid Waste` <br /> name 468-3066 -- <br /> Other: o�� �,+L ✓ -�— <br /> (describe) �a�U��f� fou✓L54,� <br /> _Word of Mouth I O� <br /> n <br /> Official Use Only � a . CMS" <br /> II <br />