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11955 White Rock Rd. <br /> ­-&.#.v S � Rancho Cordova,CA 95742 Date: 1/30/2019 C 4� <br /> (916) 351-0990 <br /> Time: 10:10 AM <br /> CONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR WASTE CHECK-IN AND CERTIFICATION <br /> RECEIPT AND CERTIfICATION STATEMENT <br /> To be completed by the generator: <br /> I certify that the following information is correct,and I have read and understand the requirements for participation in the Stericycle Conditionally EiZempt <br /> Small Quantity Generator Waste Acceptance Program.I further certify that I am a Conditionally Exempt Small Quantity Generator as defined by Federal and <br /> Caiifornla State Regulations,and this quantity of waste does not exceed the specified limits for the type of waste being disposed.If this waste is later found <br /> to exceed small quantity limits or contain materials not accepted under this program I agree to complete a hazardous waste manifest and comply with <br /> other sate regulations as appropriate. <br /> Company Name: Hewitt Alignment Service Company Rep: Samantha Esposito <br /> Company Address: 925 S EI Dorado St. EPA ID# CAD 983 641 093 <br /> Stockton, CA 95206 Signature: <br /> Phone Number: 209-948-8433 Title:( � ,vY14vq Dater <br /> TO BE COMPLETED BY STERICYCLE CHECK-IN ATTENDANT <br /> General Waste Description(Chemical Haz. A:y State S/L #of Container Total waste Total Waste Disp Cost <br /> Constituent,Ph,WTC.) Class waste Code Cont. Type/Size (gal/ft) (pounds) Meth <br /> Fluorescent Bulbs UW S 27 8`//41 180` $27.00 <br /> E <br /> Oil Filters NR S 1 10 gal 33 filters $0.00 <br /> Lanolin Solvent NR L 2 5 gal 10 gal $82.50 <br /> Brake Fluid NR L 1 5 gal 2 gal $41.25 <br /> Sweep NR S 1 5 gal 31 lbs $43.40 <br /> Bench Grinder Dust NR S 1 5 lbs $7.00 <br /> Carburetor Cleaner NR L 1 1 gal 1/2 tit $8.25 <br /> i <br /> Processing Fee $20.00 <br /> Method of Pyrnnt: Cash Check# Inv Total Paid: $229.40 <br /> Stericycle Check-in Attendants Initials: Date: <br />