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CQ Steric cle' 11555 WHf6P.Rf CK ROAD Date of Event: <br /> Y RANCHO CORDOVA,CA 95742 Time: <br /> (916)351-09Li0 Informed: ----` — <br /> Thes Participated: <br /> CONDPPIONALLY EXEMPT SMALL WAHTE <br /> CRECK-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 /> Stericycle Conditionally Exempt Small Quantity Generator Waste Acceptance Program, I fiuthor.certify that.I am a Conditionally Exempt. <br /> Small Quantity Generator as defined by Federal and CalifoCnia,StW teatylatians,and this quantity of waste does 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 contain materials not accepted <br /> wider this program,I agreo to complete a hazardous waste manifest and comply with other state regulations as appropriate. <br /> COMPANY NAME: +..t ,� ., j' ,7C...c.' i��I;iVl,l (�{iL�i_C. COMPANYREP: J1; %'Ua�Y; %{%1.7i-�it, <br /> COMPANYADDECE55: ` �,1'Ii.C,"��- 1� ) EPA ID#: t �(Ii_. ' ( (� .,•;<IC' jL.I <br /> CITY,STATE,ZIP: SIGNA3'.U$ii: _ <br /> COMPANY PHONE: �' "r j) .',';t. (.. )! , TTTLE: _M . �l DATE: A D I <br /> TO BE COMPLETED BY STERICYCLE CHECK-IN ATTENDANT <br /> GENERAL WASTE DESCRIPTION HAZARD AH STATE S/ /OF CONTARM WASTE WT(LB) DW COST <br /> (f't1C CAL CONSIITURNT.Ph.,PLCa _ CLASS WASI1; CODE L COKL TYPEISIZE A&MINT Muni ��JJ <br /> METHOD OF PAYMENT: CASH ❑ CHECK I4' CHECK NO. J 1� TOTAL PAID$ L�' <br /> STERiCYCLEC.HECK-INATCENDANTS INTMALS.. ... _ DATE <br /> PSC.m7 ILEV005 CHECK-IN RECEIPT <br />