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/U0/ZJ/ZU10 TUB 14:4g r'AX IQ�00Z/QO`L <br /> 4 Jury 2 �,���� <br /> 00 11855 W1i1'1'IrxOCKltUAl) ate m1_ June-24-2-0-1, <br /> Stericycle' RANCHO CORDOVA,CA 95742 <br /> (916).151-0980 ENVIRONMENTAL <br /> PERMIf"W [We <br /> .. <br /> CONDITIONALLY EXEMPT SMALL QUANTITY GE NERATOR WASTE <br /> C11ICK-1N RECEIPT AND CERTIFICATION STATEMENT <br /> TO BE COMPLETED BY GENERATOR: � <br /> 1 certify that the following information is correct,and I'have Tead and.understand the requirements for participation in the <br /> Stericycle Conditionally Exempt Small Quantity Genorator WasttSAcoaptuuco Program. I hu'Iher certify that 1 am a Conditionally lixempt <br /> Small Quantity Generator as defined by Federal and CAlif6iiiia State regulations,.and this quantity of waste sloes not oxeced the specified <br /> limits for Nie type of waste being disposed. if this waste is liter-found to exeued am'0 quantity limits or contain materials not accepted <br /> under this program,i agree to complete a hazardous waste inanifear AUIt)comply with other.stete regulations as appropriate. <br /> COMPANY NAME: J.& L.Market COMPANYREP: <br /> Eugenia-Yal-dez...-._::__.... <br /> .W..... ... . .. <br /> COMPANVADDRTSS: X1 5 S_ E Dorado S_ EPAJUM; <br /> crrY,S'ra,'>J,LII': French. .a fgR. .A 950 1 SIGNA <br /> COMPANY PlIONE: (209) 982.0897 I'i'I'L �l. -DATE: Gn. <br /> l <br /> TO BE COMI'LCTED HY STERYCYCLE CHECK-IN NI TENDANT' <br /> GENBRAL WASTE DESCRIPTION IiAZARD AH STATE 91 #OF CONTAINHR WAS111H W'1(LE) <br /> CHUM MAL CU STJ I UUNP P X. CLASS WASTE r ,ZE AMOUNT hRRTH <br /> Bel Filters 4.1 10 4 <br /> Rain Gas 3 1 , <br /> Elgar41 6 3.60 <br /> Processing Fee �� -------- _^ 20 <br /> METHOD OF PAYMENT: CASH ❑ CHECK CHECK NO. i.,'_,°: TOTAL PAID$ 46.30 <br /> STERICYCLF C'I FC:K-TN ATTENDANI S INTTIALS <`a` ' _ i�ATE .o -J, <br /> PSC-207 R>:vo4n5 C REC:K-1N RLC EIPT <br /> b <br />