Laserfiche WebLink
..*CLABLE MATERIALS REPORTING F(.. .10 <br />PLEASE PRINT OR TYPE ALL INFORMATION <br />(See instmcdons an reverse) <br />WHEN COMPLETED, RETUn N THIS FORM TO <br />THE LOCAL HEALTH O F F I C g R 0 R OT H a R AUTHORIZED PUBLIC OFFICER AT: <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />304 E. WEBER AVE, 3RD FLOOR <br />STOCKTON, CA 95202 <br />(209) 468-3427 <br />DATES OF REPORTING PERIOD: Beginning Date: Ending Date: <br />FACILITY THAT RECYCLES THE MATERIAL (Please print or type). <br />A. RECYCLING FACILITY <br />Facility EPA Identification Number C,41- d-919 <br />Facility Name R <br />d w-72 CL -01 re-� L/t/ <br />E <br />Facility Address Z= <br />City .d <br />County <br />.9fid <br />State e 'Ir <br />rip <br />Contact: Last Name zwea <br />&,if- � <br />First Name <br />Telephone '__0 z -:: i% <br />FAX <br />B. OWNER OR OPERATOR OF THE RECYCLING FACILITY. <br />Name <br />Address r <br />'f <br />city <br />State <br />Zip <br />Telephone <br />✓FAX <br />GENERATOR OF THE RECYCLABLE MATERIAL (Please print or type). <br />Was the generator of the material the same as the recycler? *C1 No fA yes <br />If yes, then leave Section N blank and proceed to Section IV. <br />A. GENERATING FA C11.17Y. <br />Facility EPA Identification Number <br />Facility Name <br />Facility Address <br />City <br />State <br />Contact: Last Name <br />Telephone <br />S. OWNER OR OPERATOR OF THE GENERATING FACILITY. <br />Name <br />Address <br />city <br />Telephone <br />County <br />Zip <br />First Name <br />FAX <br />State Zip <br />FAX <br />Rev: &7&92 Page I of 2 <br />