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11855 White Rock Rd. <br /> e tic : ,cf Rancho Cordova, CA 95742 Date: 7/1/2020 <br /> (916) 351-0980 <br /> Time: 8:45 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 other <br /> state regulations as appropriate. <br /> Cbhioany Name: LPS Water Company Company Rep: Denyse Arnerich <br /> Company Address: 14900 W. HWY 12 EPA ID # CAL 000 420 959 <br /> Lodi, CA 95242 Signature: 'w <br /> Phone Number: 209-482-8559 Title: QA. Date: <br /> AND � <br /> ...... ...... ...... . <br /> TO BE COMPLETED BY STERICYCLE CHECK-IN ATTENDANT <br /> General Waste Description(Chemical Haz. AH State #of Container Total Waste Total Waste Disp <br /> Constituent,Ph,WTC:) : Class Waste Code SQL Cont. Type/Size (gal/ft) (pounds) Meth COSI <br /> 8' Fluorescent Bulbs UW S 2 Boxed 16' $2.40 <br /> . <br /> Processing Fee $20.00 <br /> Method of Pymnt: Cash - Check# Inv Total Paid: $22.40 <br /> Stericycle Check-In Attendants Initials: Date: ^ <br />