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11855 White Rock Rd . <br /> � <br /> Rancho Cordova , CA 95742 Date , 1/ 2/ 2020 <br /> "0 stericycl 916 351 - 0980 <br /> l'irat) CIL <br /> Time , 3 : 30 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 . 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 : Naglee Burk Irrigation District Company Rep : Robert Mehlhaff <br /> Company Address : 4600 S . Tracy Blvd . STE . 114 EPA ID # CAL 000 360 640 <br /> Tracy, CA 95377 Signature : � �/� <br /> Phone Number ; 209 - 835 - 3232 Title : Date ; / Q <br /> TO BE COMPLETED BY STERICYCLE CHECK- IN ATTENDANT <br /> General Waste Description ( Chemical Haz . AH State S/ t 9 of Container Total Waste Total Waste Disp Meth <br /> COSI <br /> Constituent, Ph, WTC , ) Class Waste Code Cont. Type/Size (gal / ft) ( pounds ) Me <br /> Motor Oil <br /> NR L 2 55 gal $ 22 . 00 <br /> $ 20 . 00 <br /> Processing Fee El� <br /> L11EEEE Inv Total Paid : $ 42 . 00 <br /> Method of Pymnt : Cash Check# - <br /> Date : <br /> Stericycle Check- In Attendants Initials : � .— <br />