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bterlcydv <br /> o cancan Cordova,,!-."t d5742 Date: <br /> �sSsirtr:�rr:e:tt,31 So$.fti�rr�. {�?6a3s3-1398G <br /> . E e: <br /> COWVDMNALL EXBAFf SMALL QUAikFFV GUMERATOR Arii Lr,';; CHECK-IN .AND CERMIFICATION <br /> RECEIP N AND CEG `wE ,CEP" ON STATEMENT <br /> To be completed-Ifhy the genet or <br /> I certify that the following information is correct,and.,have recd and uneerstanc th a r."wrarrients for participation in the 5tericycle Conditionally Exempt <br /> Small Quantity Generator Waste Acceptance Program.I further certify that]am a Conditionally Exempt Small quantity Generator as defined by Federal and <br /> California State kegulations,and this quantity of waste does not exceed the specified limits sor the type of waste being disposed.if this waste is later found <br /> to exceed small quantity limits or contain materials n,-;t accepted under this program 1 agree to complete a hazardous waste manifest and comply with <br /> other state regi dl!Vans::s appropriate. <br /> Company Naa:.na- CGnilp-Ony Rep: <br /> Company Add ess: `135i< �� f` � � � EPA M# �. <br /> f _ Signature: <br /> Phone Numbcr'(2,J-g� ��,- .��'�� - _ TiVe Date. 62- <br /> Genera: Vi45te Description(Chem ca? H_z. Ai; z State i F of ( Container 7ot2l Waste � Totai Waste I Gish] 1 <br /> FF�� vv-s­ <br /> �' r'I1' {y t ` Cost <br /> a..Usi3LILlSCISL,r!£y vl[•tC ..1QSS, vu-sJ t co-,;e i..J�iL. Eypal.3 iZG (oaEl"' f (pounds', rvlwLir ; <br /> +. <br /> 14 <br /> - - -_ �^-_„ j7' <br /> ----------- <br /> g <br /> '� <br /> F <br /> I � <br /> i _4 ------- ^------ --g Fee <br /> Method of Pyl^:nt: cash checi: jotal Paid: <br /> Stericycle Chet i In Attendants <br />