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Staff Member Signature: <br />Staff Member Name (print): <br />Ertvironmentai Heakth Referral:. <br />yehicle License Plate Number (if applicable): <br />........... <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) 468-3068 <br />Customer Information <br />Name (print) <br />1 -r-- . • <br />rO U1'7 4 .1-16 0 <br />Date <br />5 73 Street Ad <br />2-0 Nr F5 1--- <br />City/State/Zip. Code . . <br />.--kil d J) <br />(V <br />ck <br />Area Code A TelaPhorte Number <br />15- )3 - 7736 <br />I declare, under penalty ("perjury, that The waste I <br />brought to this facility was generated by a resident and <br />was not generated by a business. <br />CUetOnler 'Signature <br />, - - — - - -, 1 Ls__ --- --- <br />Meted* Received _ 'Quantity (10 pity DateProoessed. <br />6-iCellut) E.,(-- 4 , k 1 -_,-a rs ct..-»a0A-, -6-15f.2„3 <br />. YA.,,(-_,. i <br /> _ <br />., , <br />i <br />To be coropleted:by HEW Facility Stafttaerctiar <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.