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11855 White Rock Fid. <br /> a <br /> e.r;c c. Rancho Cordova, CA 95742 Date: 1/22/2020 <br /> (916) 351-0980 <br /> Time: 8:15 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 Conditionafly 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 cornplete a hazardous waste manifest and comply with <br /> other state regulations as appropriate. <br /> Company Name: Nasco Electric Sign Company, Inc Company Rep: Pam Lindsey <br /> Company Address: 3180 N Ad Art Road EPA I❑ CA 000 290 917 <br /> Stockton, CA 95215 S.iggnatur : L <br /> Phone Number: 209-931-1924 Title:.6 - t� <br /> at <br /> TO BE COMPLETED BY ST£RICYCLE CHECK-IN ATTENDANT <br /> General Waste Description(Chemical Haz. AH 50.te SJL #of Container Totat Waste Total Waste [lisp <br /> Constituent,Ph,WTC.) Class Wasce Code Cont. Type/size (gal ft) (pounds) Meth Cost <br /> Polyurethane Paint 3 L 9 1 gal 9 gal $31.50 <br /> '`ontam. Rags NR S 3 Boxes 45 lbs $63.00 <br /> „ontam. Filters NR 5 2 Boxes 57 lbs NSC <br /> Contam. Motor ail NR L 3 5 gal 15 gal $52.50 <br /> Processing Fee $20.00 <br /> Method of Pymnt: Cash Check# Inv Total Paid: $167.00 <br /> ricycle Check-In Attendants Initials: Date: <br />