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s <br /> # 11855 White,Rack Rd. <br /> Stericycle,, Rancho Cordova CA..742 <br /> Date: 1/2/2020 <br /> } �• } (916) 351-0980 <br /> i •:y.1�-41Y.:� :.�t+wtif9f.,ti rest <br /> Time: 3:45 PM <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 Exempt <br /> Small Quantity Generator Waste Acceptance Program.l further certify that I am a Conditionally Exempt small Quantity Generator as defined by Federal and <br /> California 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 state regulations as appropriate. <br /> Company Name: Lathrop Woodworks Company Rep: Sonya Looney <br /> Company Address: 16175 McKinley Ave. EPA ID# CAL 000 03 9 <br /> Lathrop, CA 95330 Signature: <br /> Phone Number: 209-858-4173 Title: - Dat . . r <br /> TO BE COMPLETED BY STERICYCLE CHECK-IN ATTEN ANT <br /> General Waste Description(Chemical Haz. A» State #of Container Total Waste Total Waste 01sp <br /> Constituent,Ph,WTC.) Class Waste Code s�1 Cont. Type/Size (gal/ft) (pounds) Meth Cost <br /> Motor Oil/Water NR L 4 5 gal 20 gal $70.00 <br /> Processing Fee $20.00 <br /> Method of Pynnnt: Cash Check# Inv Total Paid: $90,00 <br /> 5tericycle Check-In Attendants Initials: r Date: <br />