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• oma® 11855 WHITE ROCK ROAD Date of Event: <br /> 004D Stericycle' RANCHOCORDOVA,CA 95742 Time: <br /> (916)351-0980 Informed: <br /> Times 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 /> Stericycle Conditionally Exempt Small Quantity Generator Waste Acceptance Program. I further certify that I am a Conditionally Exempt <br /> Small Quantity Generator as defined by Federal and California State regulations,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 /> under this program,I agree to complete a hazardous waste manifest and comply with other state regulations assappropriate. <br /> COMPANY NAME: Ct}til/U t (�J�e I✓UIYLI � COMPANYREP: 6)kVi /� J00( h(, <br /> COMPANY ADDRESS: �L l u, EPA ID#: Cot F)QQ3gq <br /> CITY,STATE,ZD': Ltli 04 qF2-L' SIGNATURE: <br /> COMPANY PHONE: Qvq) , qty DC) TITLE: DATE: <br /> TO BE COMPLETED BY STERICYCLE CHECK-IN ATTENDANT <br /> GENERAL WASTE DESCRIPTION HAZARD AH STATE S/ #OF CONTAINER WASTE WT(LB) DLSP. COST <br /> CHEt CALCONSTrTU@ TPh. STC. CLASS WASTE CODE L CANT yTYPE/SIZ.E AMOUNT him <br /> r W C�CI� J <br /> roc wn Zv <br /> METHOD OF PAYMENT: CASH ❑ CHECK ❑ CHECK NO. TOTAL PAID$ `I j-r q0 <br /> STERICYCLE CHECK-IN ATTENDANTS INITIALS DATE <br /> escam REvoens CHECK-IN RECEIPT <br />