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i• 1 Ia55 WHtTE ROCK ROAD pate of Event: /f Lf((fp <br /> ®'�® Stericye(e' RANCHO CORDOVA,CA 95747 '1 'tNL72a.rr <br /> (916)351-0980 Informed: _ <br /> Times Participated: <br /> CONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR WASTE <br /> CHECK-IN RECEIPTAND CERTrFfCATION KIATEMENT <br /> TO BE COMPLETED BYGENERATOR <br /> I certify.that the following information is correct,and I have road and understand the requirements for participation in.the <br /> Staricycle Conditionally Exempt Small Quantity Generator Waste Acceptance Program. I further certify that I am it Conditionally Exempt <br /> Small Quantity(lenerator as defined by Federal and California State regulations,and this quantity of waste does ant 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.agreo to complete a hazardous waste manifest aed comply with other state re <br /> gulations as appropriate. <br /> COMPANYNAME:. fialy 1'iSh COMPANYREP: I Vny IY Iltir9WlBl <br /> fin <br /> COMPANY ADDRFSS! <br /> s (.(w,/L�cj �+yC_ F,PA ID#: , 7 �-�mss! <br /> CITY,STATE, ZIP: � (.�%' (4 61!j 2,05 SIGNATURE' <br /> COMPANY PHONE: TITLE: 7`irRlaG.ituFvr.,t ,DpT'g; <br /> TO BE COMPLETED BY STERICYCLE CHECK-IN ATTENDANT„ <br /> -GENERA!.WASTE DESC1i1PTION HAZARD-( AH _S <br /> L,CHS&WAL CONSTM IM.,ETC.) CLASS WA�STE, TATE S/ p OF CONTAINER 'WASTE lYr(LB) DLSP. CAST- 2 <br /> CODE L CONT 7`1'.PGf9IT.E AMOUNT <br /> F'lWyesw14 T7Arl-3ZS tMN / <br /> olo . : . 'FUGe s U w 4'• Zl fifD'• 3L i <br /> er'.0 kjs iNVV fo/o 5 <br /> 551 n Ze (a ! 7& <br /> METHOI)SOF PAYMENT: CASH 'O CHECK CHECK NO. 9 CE11j TOTAL PAID <br /> STERICYCLE CHECK-IN ATTENDANTS INITIALS G Z-. - . E. DATE �/ <br /> escaar savours t'&K INTRECEIPT <br />