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11855 White Rock Rd. <br /> iencycle Rancho Cordova, CA 95742 1/29/2020 <br /> (916) 351-0980 <br /> Time: 9:1S AM <br /> CONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR WASTE CHECK-IN AND C iERTIFICATION <br /> RECEIPT AND CERTIFICATION STATEMENT <br /> To be completed by the generator: <br /> I <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 f am a Conditionally Exempt Small Quantity Generator a I'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 his waste is latter found <br /> to exceed small quantity limits or contain materials not accepted under this program I agree to complete a hazardous waste man(fest and comply with <br /> other state regulations as appropriate. <br /> Company Name: California Welding Supply Company Rep: Peter Vacco j <br /> Company Address: 817 S. Center Street EPA ID # Al_000 301 256 <br /> Stockton, CA 95206 Signature: <br /> Phone Number: 209-471-9226 Title:– "Date: II C� <br /> TO BE COMPLETED BY STERICYCLE CHECK-IN ATTENDANT <br /> General Waste Description(Chemical Haz. 7AH State S t #of Container Total Waste Total Waste wisp <br /> Constituent,Ph,WTC.) Class Code Conk Type/Size ;gal/ft; (pounds) Meth cos, t <br /> Blast Media 6.1 S 3 5 gal 162 lbs $22§.80 <br /> Latex Paint NR L 1 5 gal 4 gal iNC <br /> i <br /> 1 <br /> I <br /> i <br /> Processing Fee <br /> Method of Pymnt: Cash Check# Le Inv Total Paid: $246,80 <br /> Stericycle Cheek-In Attendants Initials: ____ I — <br /> Date: Ii ! 25 <br />