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r <br /> •-d (ttt'i5 lV[il ff, E(Ut:n li(.Yl;I) f)ar.ut I:�tin: <br /> U 5fc�tic.ycfe' RANCi•f0C0ftt)(-JVFl,CA 9;742. Not ( �� <br /> (91 C') 351.0()?0 <br /> ' 1llUeti h:tl(0.a1);th:Cl —_•__j_S.L-:_L.:=•--� <br /> CONDITIONALLY LiXE-NIPT Sl+✓IAL L QUAi\TITY 4C�EN'ERATOR wA'S"FE <br /> CRE'CK-M R sCEH'T AND CER"tTI ICAXION STATL,N/1-C.Nt-C <br /> TO BE'COj'%IPLE'I'ED lel'GEL'1ERATOR: -------- <br /> I certify that tbe.following information is correct,and I have read and understand the requirements for participation in the <br /> ricycle Conditionally Exempt Small Quantity Generator Waste Acceptanre Program. I further certify that I am a Conditionally Ex-e(upt <br /> all Quantity Generator as dermed by Federal and CatiEor:ia Stale regu(atinrs,and this giraritity of waste does noterceed the specified <br /> its for the type of waste being disposed. If alis waste is later found to exceed small quantity limits or contain materials not accented <br /> ler this program(,I agree to complete a hazardous waste manifest and co:trply with other state regulations as approp(iate. <br /> b4PANY NAME: !l'�i' %ty"' C.• COMPANY ILP: YtJ�'tL <br /> MPANYADDRESS: EPA[DU: Ck1k-T <br /> STATE,ZLP: L T U r ' 2 ] �c�t(22� _ SIGNATURE'- - t Y ; 6-- <br /> MP.ANY PRONE: �J 1 � 'l`7� 'I�LES� r,f,f HATE: <br /> TO BE COMTLETED BY STEMCYCI,E CHECK--IN ATTENDANT <br /> ENERAL WASTE DESCRiP fON HAZARD AH STATE S/ N OF Cbt fi'AR-tMR WASTB vI T(LB) DDIIS� COST <br /> F.NQCAL CON PI ETC. C WASTE CODE L CONI' TYPEISIZE AMO[JNT <br /> t � <br /> CHO D OF 11AY NIF. (C: CASH C3 CHECK C3 CHECC NO._ 'E�C3TAZ,i' <br /> RICYCLE CHECK.-fN ATTENDANTS W-ULALLS _° -----•• DATE rr REvo•uts <br /> to O>aKw , <br />