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06/10/2016 Wall 10115 VAX IQ,19v 2/992 <br /> 0 11955 Vn=-,RICK ROAD LLL&Ir —v - Date of ttvcm: Aur uat 10,2010,20116— <br /> 0 0 Stericycte' RANCHO CORDOYA,CA95742 AUG 2 3 < t, 0 49- 11ee: <br /> • (916)351-0960 •AUG <br /> 2016 rnftrmcd: <br /> r 'IYmca Yamricipated; <br /> a. <br /> CONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR WASTE <br /> CHECK-IN RECEIPT AND CERTIFICATION STATEMENT <br /> 'CO BE COMPLETED BY GENERATOR: <br /> I uertlfy that the following inf trdlation is correct,and I have read and understand the regoiremems for partieipation in(he <br /> Stericycle Conditionally Exempt Small Quantity Generator WasleAumptanm Program. I fiditur artily that f am a Conditionally%empt <br /> Small Quantity Gemmator as defined try federal and Cafifoinia State ra&ations,and this mlontity of waste does not execed the specified <br /> limits fdr the type of waste being disposed. If this waste is later found to excnod small quantity limits or contain materials not accepted <br /> trader this program,I egrcc to complete a ha2mdaas waste manifest and comply with other state[regulations as appropriate. <br /> 0 <br /> coinPANYNAMI¢: ._Food Mart Gasoline cOMrnmREP; . Joginder Lal <br /> COMPANYADDRESs: ..2185 E. Fremont St. lrAIDB: CAL P00379401 <br /> CrI'Y,STA'r'E,Zlrs, Stockton. CA 952055' SIGNATURE. " <br /> COMPANYPHONEI (209) ....547;1700 11TLE: _ti� /S., DATE; p o <br /> TO BE COMPLETED BY STERICYCLE CiIECi m ATTr,.NDANT <br /> 0123NENAL WA51E I)ESCILYI'nIN HAZARD AH STATE 91 AOR CONTATN911 WASTE (m)) LUMP. COST <br /> CHHMCAL CONSTITUENT,Ph, CLASS WASTE CODE L CONT =agti A MFTH <br /> Absorbent 9 1 I 2, sy6 <br /> rood <br /> Fuel Hoses 4.1 8 5S <br /> 1.30/pound) <br /> i <br /> Oil Filters 8 N C <br /> Processing Fee 20- <br /> It I <br /> METHOD OF PAYMENT: CAS11�t 011141K O CHECKNO._- TOTAL PAIfDS 5v <br /> ,., <br /> STERICYCLN CHECK-IN AT115NUANI:3 INITIALS DATE 1 1 b SO <br /> rsam nnv ens - CHECK-IN RECEIPT <br />