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...... . ....... <br />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 />1 ---- <br />,ti I a -1 6 Vi <br />Date <br />_-) 7 3 Street Add <br />tfty/StatelZfp Cede <br />_ 4 /6,pi cet ei 5 2(3 <br />Area Code & Telephone Ninnber . <br />2 0 e.e — 5 l3 - 6 7 73 <br />1 declare, under penalty &perjury, that the waste I <br />brought to this twiny was generated by a resident and <br />was was not generated by a business. <br />CusmerSIgnauir. . <br />7Y <br />1 <br />- <br />MOWS RaCehrerf Quantity (10194k <br />6•)c-ifiwp <br />Dots Processed <br />5177.— <br />ir1kvse_, c254 <br />To be coMpleted:by HAN Facility Staff *mbar <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: <br />Staff Member Member Name (print): It CIA ki Q.1 IU <br />Environmental Heatth Referral:. op N <br />Vehicle License Plate Number (if applicable): • <br />4? COA:*ciA-b.'