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i LI8546VfM'L Pk)CK ICOAD Date of Event: <br /> o� Stericycle' RANCI F()COIWOVA,CA 95742T � <br /> Time: <br /> (916)351-0980 Informed: <br /> Times Participated: <br /> CONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR WASTE <br /> CHECK-IN RECEIPT AND CERTIFICATION STATEMENT <br /> TO BE COMPLETER RY GENERATOR: ' <br /> I certify that the following information is correct,and I have read and understand the requirements for participation in the <br /> Stericycle Conditionally Exempt Small Quantity Generator Waste Acceptance Program. I further certify that I am a Conditionally Exempt <br /> Small Quantity Generator as defined by Federal and California State regulations,and this quantity of waste does not exceed the specified <br /> limits for the type of waste being disposed. If this waste is later form to exceed&mafl gpantity limits oT contain materials not accepted <br /> under this program,I agree to complete a hazardous waste manifest andcomply with other state regulations as appropriate, <br /> COMPANY NAME: 9-0-r'r-�0 5an a4';r` �� COMPANY REP: <br /> COMPANY ADDRESS: Mu l `:", P"A EPA ID#: LAD Z <br /> CITY,STATE,ZIP: cDjbLy (fir � SIGNATURE: <br /> ICOMPANY1H!(!'NE: <br /> TO DE C:OWLETED BY'ST RICYCL'E C CK-IN ATTENY ANT <br /> GENERAL WASTE DESCRIPTION HAZARD AH STATE S/ #OF CONTAINER WASTE WT(LB) DISP: COST <br /> CHEMICAL CONSTITUENT Ph.,ETC. CLASS WASTE CODE L CONT TYPESIZE AMOUNT METH <br /> CC-14-5 ` <br /> S ���f� )`i ILA <br /> eb <br /> V 5 I} <br /> AL <br /> 7,57 <br /> �i T-05 3. <br /> i <br /> �a <br /> 101PHOaD OF a A'T1WEN1% CA&H 0 CHEEK—'K Q C-9ECiK INN. t�Ii�L PA1D 16 it�� E °�57 <br /> STERICYCLE CHECK-SIN ATTENDANTS'1N'I ALS d, DATE <br /> rsc-20REV 04/15 - - --- CHECK-rN RECEIPT <br /> CREDIT 4RD ENDING IN <br />