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REEIE <br /> ar&o I I'WHITE"OCK ROAD Date of&vent: f L' <br /> ® StepicyeBe RANCHOCORDOYA,CA 95742 FEB 0 6 2017 Tare: l f f�.- <br /> (916)351-0980 j. .�5vy uyn Info ml=': <br /> ENVIRONMENTAL HEALTHTimm Participated: ` <br /> DEPT T <br /> CONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR WASTE <br /> CHECK-IN I2ECEIPTANDCERTI7FICATION STATEMLrNT <br /> TO RE COMPLETED RY GENERATOR: <br /> I certify.that the following information is correct,and I have read and understand the requirements for participation in.the <br /> Sterieycle Conditionally Exempt Small Quantity Generator Waste Acceptance ProgmaL 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 quzattity limits or contain materiels not aecepted <br /> under this Progrrttm.I.agree to complete a•hazaadons waste manifest and comply with other state regulatiom as appropriate. <br /> COMPANY NAME:. 611"�Y1�F0F FYGSFI COMPANYREP: fUYlt' .fY,lltilr(�lL101 <br /> COMPANY ADDRESS: 115 'S uw,/ EPAID#: <br /> CITY,STATE,ZIP: , s-f t7( {�, CA 152A6, SIGNATURE _ <br /> COMPANY PRONE: TITLE: <br /> 7`dAl�t7G9#.,h-xe�, DATE <br /> To B " OOMP'LETED BYSTERICYCLE CHECK-IN ATTENDANT_ <br /> ..GENERAL WASTE 4E$C[tWPTION - FfAZArdD'""` All STATE -S/ p OF CONTAINER •WASTE WT(LB) <br /> `CFiEf.•IICAL . . ETrfDEN1'.Ph ;ETC. ... CLASS WASTE• - CODE L @W-,r r 'NPI r2:t; •Af204:8a'C M@Pii. <br /> 1 1llm dSlps1 F Tu1>cS LbW 1 ZZ-4 r &D <br /> Fr1 Akjs W <br /> pmb& <br /> SSI n -F•ee (ak( 764 <br /> ATETETOD SOF PAYMENT: )CASH '0 CHECK' CHECK NO..= &I 6 TOTAL PAID S.._ -(. <br /> STERICYCLE CHECK-IN ATTENDANTS INITIALS— C . .. __. DATE : �� G <br /> PSC-207aevwns CMCK IN RECEIPT <br />