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I f955 WH(I-E !<ChCK R 0 AD Datc oi-Evcr1I <br /> Stericycle' RANCHO CORDOVA.CA 957,12 Tirnt <br /> (9IE)35[-0980 <br /> "Filmes Paraicipatcd: 6 � <br /> CONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR WASTE <br /> CHECK-IN RECEIPT AND CERTTFICA'1WN STATEMENT <br /> TO IBE COMPLETED BY GENE %TOR: <br /> I certify that the following information is correct, and I have read and understand the requirements for participation in the <br /> ricycle Conditionally Exempt Small Quantity Generator Waste Acceptance Program. I further certify that I am a Conditionally Exempt <br /> all Quantity Generator as defined by Federal and California State regulations,and.this quantity of waste does not exceed the specified <br /> its for the type of waste beigg disposed. If ti is waste is later foundto exceed small gu mtity runts of contain materials not accepted <br /> 'er this program, I agree to complete a hazardous waste manifest and comply with other state regulations as appropriate. <br /> NTPANY NAME: ( fi <br /> COMPANY REP�v' JP: V' WU <br /> %IPANYADDRESS: EPAID9: <br /> 'Y,STATE,ZIF: Ci ._ : � �,' .C�� SIGNATURE: <br /> VIPANY PHONE: ( ) TITLE: DATE: <br /> BE COWLETE-D.BY STE CYCIX CHECK-IN ATTENDANT <br /> ,14MU&WASTE DESCRIPTION . HAZARD Aff STATE S/ #OF CONTAINER WASTE WT(LB) DISir COST' <br /> CAI.( P EIC. CLASS WASTE CODE L CONT TYPESIZE AMOUNT /- <br /> 61 <br /> - = - ,fir <br /> O PAYMENT: CASH U CEECK :I3 C AGK No-_ i�TAL PAID� ~t <br /> � - c <br /> _C 1 CLE CHECK-Mr ATM-NMAMS UgrrLkLS DATE <br /> ULEV041I5 , CHECK-1.N'RECEIPT <br /> F <br /> f <br />