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E <br /> 11855 White Rock Rd. <br /> Stericycle,G Rancho Cordova, CA 95742Die: 2/12/2020 <br /> (916) 351-0980 <br /> Time: 8:45 AM <br /> CONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR WASTE CHECK-IN AND I ERTIFICA ION <br /> ------------------ <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 Stericy cle Conditional) Exempt <br /> Small Quantity Generator Waste Acceptance Program, I further certify that I am a Conditionally Exempt Small Quantity Generator I s 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.I I this waste is fa er found <br /> to exceed small quantity limits or contain materiais not accepted under this program I agree to complete a hazardous waste ma'ifest and comply with <br /> other state regulations as appropriate. <br /> Company Name: California Welding supply Company Rep: Pet r Vacuo <br /> Company Address: 817 S. Center Street EPA ID it CAL 0 0 301 256 <br /> Stockton, CA 95206 Signature: <br /> Phone Number. 209-471-9226 title: � ; �� Dated' � <br /> TO BE COMPLETED BY STERICYCLE CHECK-IN ATTENDANT <br /> General Waste Description(Chemical Haz. AM State 5/L #o= Container Total waste Total Waste i3isp <br /> constituent,Ph,WTC.) Class Waste Code Cont. Type/Size (gal/ft) (pounds) Meth C'St <br /> Blast Media 6.1 S 3 5 gal 162 fbs $22 ,80 <br /> Paint 3i L 2 2.5 gal 5 gal $17.50 <br /> 1� <br /> 1 <br /> 1 <br /> 1 <br /> Processing Fee $20:0:0 <br /> Method of Pymnt: Cash Check# Inv Total Paid: $264.30 <br /> Stericycle Check-In Attendan:t5:1nitials: �� Date: <br />