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i • <br /> i' 11855 WHITE ROCK ROAD Date of Event; March 18 2016 <br /> StePicytie' RANCHO CORDOVA,CA 45742 Time i am <br /> r (916)1St-0980 Informed: <br /> I)MO,gPerticipated: <br /> CONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR WASTE <br /> CHECK-IN RECEIPT AND CERTIFICATION STATEMENT <br /> TO BE COMPLETED BY GENERATOR: <br /> I certify that the Mlowing information is correct,and I have read and understand the requtrements for participation in the <br /> $uriayale Condit;anagy Asempt F3mali Qnantiry Generntor W astaAcecptance Pivgram. I fintharcortify that I am a CAndidwally Exempt <br /> Small Quautity Generator as defused by Federal and California State regulations,and this quantity of Waste does not exceed the specified <br /> limits for the"a of waste being dlspoeed, Ifthis waste is later found to exceed small quantity limits or contain materials not accepted <br /> under this program,l agree to comploto a hazardous waste manifest and comply with other state regulations as appropriate. <br /> COMPANY NAME: Delta Marine SoryV c@j$ COMPANY REP; Tony Faso <br /> COMPANYADDRESSi ._ 1302 W. Fremont St. EPAtD+.- CAL 00030966 <br /> CITY,STATE,ZTPs Stockton GA 95,203 SIF.NATUT <br /> COMPANYPRONE: r ..'&—'14 .. : <br /> (209) 4830384 TITLE: � DA � f <br /> TO BE COMPLETED BY STERICYCLE CHECK-IN ATTENDANT <br /> GBNERALWASTUMSCRIPTION ARD Ali STATE Si NOF CONTANM WA&TE WT(LB) Ars➢. COST <br /> _RMC CONS'[7'1'Ut3NT.P6..ETC,,,a 9s W G CODE CONT TYP E AMOUNT <br /> bsorbent Contaminated With Off 9 1 5 ai j g __13- <br /> Processing <br /> 3-Processin Fm-- <br /> .. ...... ... <br /> ee — <br /> s <br /> _ -- _ _ .. <br /> k <br /> METHOD OF PAYMENT: CASH ❑ CHECK 1 Clil1CX NO. �° _i TOTAL.PAID s 33.00 <br /> �riRlc.vct.�cl-rFct _tv,�TrElvtlnN'rslrrrl�as (r _ 24_._. DATe <br /> rsc-m; eru n,n+ t:H'KK-lNRrCFlPT f <br />