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09/09/2011 PRI 10:36 F= p�J <br /> ECEL E[) <br /> SIT t42016 <br /> 11655 WIIITEROCK ROAD ENVIRONUENTAL HEALTH vale of 6lrat $e ptember 9,2016 <br /> Staricycle' RANCHO CORDOYA,CA 93742 PERMITISEWCES h,ror: edt 3'oDpm <br /> (916)151-0980 --- <br /> 'I17M Pnoiolpatcd: <br /> CONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR WASTE, <br /> CIIECK-IN RECEIPT AND CERTIFICATION STATEMENT <br /> TO.BE COMPLETED BY GENERATOR:_, <br /> i terrify that We following information is4ou"t,and I lu ve mad and understand the mquiremerttt for participation in the <br /> Starricy4le Conditionally Exempt Small Quantity Genayator Waste Aeceptauoe Pxograul. I further certify that i am a Conditionally Exempt <br /> Small Quaaahy(icr wntox as defined by-Federal and California State regulations,and this quantity of waste does not exceed the specif(od <br /> litnits for the type of waste ivilig dispoged,.:lf.tln)8 WaBCe is later fond to exceed shall quantity liluits or contain.materials nat accepted <br /> under this program,I agree to complete a hazardous wasta manifost and comply with other state regulations as appropriate. <br /> COMPANY NAME: My.Mini Mart COMPANY REP: Vinay -COMPANY ADDRESS. 1756 N W11SOm'We_•_ EPA'D#; CAL 0002 60 <br /> CITY'. ZDh Stockton CA 95205 SIGNATURE. —�.----- ' '—'-��--�— <br /> COMPANY PHONE: (209) 341 2264_ _ TffLE: 1*1,&f}G„�/L DATE: C, -/-i-- -�-E3 <br /> TO BE COMPLETED BY STERICYCLE CHECK-IN ATTENDANT <br /> AA9),mAI.WASTTt DF.W.RAPT;ON HAZARD All S'I'VE S! kOY CONTAINPR MWT(1,13)Cl CALL SI' ' GI <br /> C. CLASS WASH I Ctn)n L (;(MT Tr A t W1 Fue1 9 , <br /> atFProressingFee 2 <br /> METHOD OP PAYMENT! CASH ®/CHECK O CHECK NO. TOTAL PAID S 22.60. <br /> S'fEitICYCLE CHLCK-IN A1TL•NDANTS INIT7Ai 4_1A ._..__ <br /> DATE I- t i__(� <br /> Rev nun+ CHECK-IN RUCISIPT <br /> rsc.� <br />