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11855 White Rock Rd . <br /> �* Slen cle Rancho Cordova , CA 95742 Date : 6 / 24/ 2020 <br /> a <br /> { 916 ) 351 - 0980 <br /> Time : 8 " 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 Exempt <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 /> 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 : Parkwoods Cleaners Company Rep : Jeff Kitto <br /> Company Address : 1901 Country Club BLVD EPA ID # CAL 01589 <br /> Stockton , CA 95204 Signature : <br /> Phone Number : 209 - 609 - 2540 Title : � Date : � •- � � - <br /> - TO BE COMPLETED BY STERICYCLE CHECK - IN ATTENDANT <br /> General Waste Description ( Chemical Flaz . AH State # of Container Total waste Total Waste Disp <br /> Constituent , Ph , WTC . ) Class waste Code Ski Cont . Type / Size ( gal / ftp ( pounds ) Meth COSI <br /> Glycol Ether Cleaning Fluid 3 L 2 4 gal 6 gal $ 21 . 00 <br /> Hydrocarbon Cleaning Fluid 3 L 4 5 gal 20 gal $ 70 . 00 <br /> Processing Fee $ 20 . 00 <br /> Method of Pymnt : Cash Check # Inv Total Paid : $ 111 . 00 <br /> Stericycle Check - In Attendants Initials : Date : ���� �� <br /> CREDIT CARD ENDING IN <br />