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CERTMIC&VIE OF DEPOMEURECYCLIIIM© <br />San Joaquhn CmVIReadona0 Ncvsehad, Ne.i•zaro:Jamo ile/gietkp Pia[Ta@mum <br />San Joaquin County Househdd Magardous Waste 1,'"aolKy <br />7850 South . A Midgeford Str,Stocfttoro, ,CA 9<52ne <br />Administrative Office: (209) 468-3C66 <br />Customer Information <br />Name (print) <br />_ I. _ _ a_ j(1\5 <br />Ode <br />i <br />Street Addrasa <br />cgo-8• <br />— <br />A _ A_ _ <br />f • _ CalgattlitigiP roDgfra <br />, 5-3-oct-raL - Ca0(.0 _ i <br />170-MI4WITZ 6 Tet[aOhiee t'aaiiiher <br />715 - .2 is. .. (0 5's 0 <br />Cm-fawn' 5giainan <br />—I - <br />Vd`Witta,t ftweiveS, <br />- . <br />raTaicafty ( b § mil DM P,PGCSZSGQ2 <br />"KA.-1_4-(L-P-2.4.44_4171--e.'15 ____ 15-.2,1 <br />1 _ _j____ <br />1 .._. _ <br />.L <br />............................. ......... _ ........... <br />canveteaby HI4liv Facility Stefigerebei. <br />Ccgrafitatilow Make-ant <br />The Son Joaquin County Hausehold Hazardous Waste Facility certifies acceptance of the <br />material referenced on this document. The [material has been ma[riaged in accordance <br />with United States Environmental Protection Agency and State of California Environmental <br />Protection Agency wte management regulations. <br />Staff Member SI nature: _ , <br />Staff Member Name (print): ID <br />Environmental Health Referral: N _ <br />Yehicle License Plate Number (if applicable): 04' . - _