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11855 WHITE ROCK ROAMDefeo€Evart: August 3,,2016 <br /> .a•,.y.ao RANCHO CORDOVA,CA 95742 11me: 10:aQam <br /> (916)351-OM Informed: <br /> 7'imaa Participated: — <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 following information is correct,and I have read and understand the requirements for participation in the <br /> Stertcycle C00411110neltY Exempt Suta11 Quantity Gmeratgr Waste Acceptance Program. I further certify that 1 am a Conditionally Exempt <br /> Small Quantity Generator as define!by Federal and California State regulations,and this quantity of waste rices not exceed the specified <br /> limits for the type of waste being disposed. If this waste is later found to exceed small quantity limits or conceit materials not accepted <br /> under this program,I agree to complete a hazardous waste manifest and comply with other state regulations as appropriate. <br /> COmPANYNAm: Vintage Pool Service & More COMPANY REP: Athena LaRue_ <br /> COMPANYADDRBS8, f78O E. Yosemite Avenue EPA ma: CAL 01} 14633 <br /> C rY,8TATE,zIP: Manteca,-CA95336 SIGNATURE: �r.� � <br /> COMPANY PHONE; (209) _549-8300 TITLR: 0(�)JLWZ� DATE: <br /> TO BE COMPLETED BY STERICYCLE CHECK-IN ATTENDANT <br /> GENERAL WASTE DESCRIPTION HAZARD AH STATE S/ f OF CONrAMER WASTE wr(t_B) DISP. CCST <br /> C04MCAL CO TnMF,N'T.Ph PPG CLASS WA97T CODE L CO T . ZE MOUNT MB7'H <br /> Chlorine TabLets 5.1 2 5 .41 7057 <br /> Conditioner/C anuric Acid 8A _ 1 5aal 10 _ 13- <br /> Clarifier 8.1 t 'Sgal — 1 44.47 <br /> Chlorine 8 -1 I 47.21 88.09 <br /> Processing Fee <br /> r <br /> t <br /> { <br /> METHOD OF PAYMENT. CASH O CHECK ❑ CHE,CK NO.--. _-- TOTAL PAID f�-2�i4.13 t <br /> cTrRTCYCLE CHECK-1N ATTENDANTS INl'r(A1.S__.�� ri. __ DATE <br /> zoQ <br /> rsam eEvara CHECK-1N RECEIPT <br />