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y m E 1855 tvl4!('f: 1_CK rcf?nEi <br /> Datc Of F_vcn6 <br /> �.o Ste!"iCycle RANCHO C%)r D0VA,CA 9$74 <br /> (916)351-0980 <br /> b,oFar�cd: _ <br /> CONDITIONALLY EKEMPT SMALL QUANTITY GENERATOR WASTE <br /> CUE CK-Il l RE'CEIPTAND CERTrIfCATfONSTATE MENT <br /> TO BE, COMPLETED BY GENERATOR: <br /> (cettify that the fottowing information is correct,and I have react and understand the requirements for participation in the — <br /> :ricycle Conditionally Exempt Small Quantity Generator Waste Acceptance Program- I further certify that l am a Conditionally Exempt <br /> raft Quantity Generator as defined by Federal and California State regulations,and this cluatltity of waste does not exceed the specified <br /> :its for the type of waste being disposed_ If this waste is tater Iniad to exceed sruati quantity limits or contain materials not accepted <br /> ier this program, l agree to comple&,a hazardous,waste manifest and comply with other state regulations m appropriate- <br /> KPANY NAME: — j 1 - COMPANY Rmvpe <br /> MPANY ADDRESS: <br /> c_ 1 �-F- 1 t�' I� EPA ID#: l._ ��-' 5r_= <br /> STATE,zit': <br /> > _� t� 7 r r fE� SIGNATURE_. <br /> MPANY P$0NE: p <br /> To BE COMPLETED By STFMCYCLE CHECK IlNATTFNDANT <br /> ENEEaAL W,Sri bt tp rFpl•T HAZARD IAH STATE— S/ #OF CONITAWM . '*ASI Wr(LB) DMS- COST <br /> iMICAt..C'L?M�'riT tJfJ�tT.Y1�.I`rC, CLAS WASTE GUDB L 0011! TYPESIZE AMOtJP[T <br /> "ILA, ILY'Lk <br /> d�~ EN it ENTi�L l <br /> 'H'0i3 OF PAYMENT: CASH ❑. CHECK CHECK NO. .77 TOTAL VAtl(S <br /> :tcYr--Lu-C1=tECK-WAi-IEhTDANTS ITITi`IAIS <br /> - HATE <br /> !:Y 4711, <br />