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CERTIFICATE OF DISPQSAURECYCLING <br /> San Joaquin County Regional Household Hazardous Waste Program <br /> San Joaquin County Household Hazardous waste Facility - <br /> 7850 South R.A Bridgeford Street, Stockton, CA 95206 <br /> Administrative Office: (209)468-3066 `• ��I°' `` <br /> Customer Information <br /> Name(print)-p p <br /> HP " e} L cf A- Date <br /> Street Address <br /> �r •9s 2 0,� <br /> tty7SteleBZ p Area Code&T*Wohone Number <br /> 1 declare, underpenany of penury, that ftre waste f Customer Signature <br /> brought to this facility vras generated by a+esident and <br /> was not generated by a business. �. <br /> f+>te�erialf p puarrtity (�1 gak;) t�Pcocesaed <br /> COn s .7 7 <br /> ----------------------------------------------- ----- - - --- - - ...------- -- <br /> 7a be completed by HHW Fadi ty Stott MamUr <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. <br /> Staff Member Signature: �— <br /> Staff Member Name(print): / > �� <br /> Environmental Health Referral:, I Y N <br /> Vehicle License Plate Number(if applicable): <br />