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G-4,1,10 ) 1:4— 11(.-/ ('(. <br />1 declare, under penalty & penury, that t Wade i raQtaTitaw agnmgma <br />brought to this faciWtyvves generated by ras!dent and <br />was not generated by a business. <br />Quafitialsp <br /> <br />CERTM10,-`3TE DRPOSkLIR <br /> <br />SgE J©acjadn C©ungv .Rogbcomil NwaaNgild H@REcaom nooft Pv©RI. MEM <br />San Joaquin County Household Hez.ardous Ws= Facy <br />7850 South R. A Bridgeford.StreM, accidoro, CA 05263 <br />Administrative Office: (209) 466-306s <br />Customer Information <br /> <br />Name (print) <br /> ft H DCA Street Addnees <br /> <br />16 , .7;Z (3 / CitifiStritsgiaCerffa <br /> <br />i'-',i0.74,k3c.t.p, Tate65i)nap, 'ilmr-nher <br /> <br />Itgaterket R..4mrivett <br />m y ts.0 111)ini c to <br />11 All <br />a t etaD,) PrOCC-.\--Maiii <br />Ve be ceMpleted:ay NNW Facility Staff ilaretiVaar <br />Coaffigatdon aqvartawgz <br />The San Joaquin County Household Haxardom Waste Facility cenifies acceptance of the material referenced on this document. The material has been managed in accordance with United States Environmental Protection Agency and State of Caliiinrnia Environmental Protection Agency waste management regulations, <br /> <br />Staff Member Signature: <br /> <br />. • <br />Staff Member Name (print): / / 1-) <br />Envimnmental Health Referral:. (5, N <br />6 es 0 cmA-11---A I .t i -77 Pi <br />Vehicle License Plate Number (it applica)le):