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ENVIRONMENTAL SEMMES* <br />mi) <br />FrIENED <br />entharb <br />San Joaquin County Permanent HHW Collection Facility <br />7850 South RA Bridgeford Street <br />Stockton, Ca 95206 <br />Direct: 209-468-5670 <br />Fax: 209-468-5672 <br />0 5 2007 <br />ENVIRONNIENT HEALTH <br />PERMIT/SERVICES <br />Inventory Form/ Waste Disposal Receipt <br />Name: ....pk•to% e_ .s em Contact: "Z-loht Pe\ <br />Address: Zs - - r\•1 <br />City: Ck\-\./vra \e Zip Code: t32O Phone No.: (241A) ct - cl 1 1/4-k1/4i <br />County: nav--‘ *EPA ID#: C2CA csc -1' --MC c)". <br />*If you do not have an EPA ID#, you may call (800) 618-6942 to obtain one. <br />Event Location/Date (if known): San Joaquin County Household Hazardous Waste Facility <br />Type of Waste Quantity Size and Type <br />of Container <br />Liquid/ <br />Solid <br />To be filled out by <br />Staff <br />Date Initial !Signature <br />(est4mp1e): Latex Paint ____t_______j_&_dplastic Liquid <br />bucket -- <br />T \J 11(1' <br />t , <br />r‘ iir <br />you need more room please attach another sheet and list as specified on this form. <br /> —2--c' <br />Date Signature