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CERTIFICATE OF DISPOSAL/RECYCLING <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 <br />Customer Information <br />Name (print) <br />J ,„.._- <br />I - ' it 0 la 11- i - 0 <br />Date <br />:) <br />._ <br />' _,) i. <br />Street Acill <br />2 - F5 k" <br />City/State/Zip Cede <br />'S .k1 <br />. , <br />e .fri it.c ei 5 26 <br />Area Code & 'Mormons Number <br />',./ T"..-. 26 er — 5--- 13,-- 6, "7 <br />I declare, under penally &perjury, that the waste <br />brought to this facility was generated by a resident and <br />was not not generated by a business. <br />CuemeT Signature / <br />i — <br />--, <br />Mato* Received. 'Quantity Oki ggil Date processed <br />6\—c"jel EZ" 1 k I ').-- CS 4? CO 4.)-C,0--0 0.-.C. ; 51;4 :3 <br />i -2.v..‹., , <br />_ <br />-, <br />, , <br />0 <br />To be coMpteted:by fffiW Facility Ste Member <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 />,. <br />Staff Member Signature: 2 0 --- - <br />Staff Member Name (print): , Ltgi ail kikdi tO <br />Environmental Health Referral:. y. N <br />Vehicle License Plate Number (if applicable):