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0 0 11853 WHITE ROCK ROAD Date of Event: ` ,I ce (p <br /> 00 0 SteriCYClev RANCHO CORDOVA, CA 95742 Tune <br /> • (916) 351-0980 Informed <br /> Y , oljliI Times Participated: <br /> CONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR WASTE <br /> CHECK—IN RECEIPT AND CERTIFICATION STATEMENT <br /> TO BE COMPLETED BY GENERATOR: <br /> I certify, that the following information is correct, and I have read and understand the requirements for participation in the <br /> Stericycle Conditionally Exempt Small Quantity Generator Waste Acceptance Program. I further certify that I am a Conditionally Exempt <br /> Small Quantity Generator as defined by Federal and California State regulations, and this quantity of waste does not exceed the specified <br /> limits for the type of waste being disposed, If this waste is later found to exceed small quantity limits or contain materials not accepted <br /> under this program, I agree to complete a hazardous waste manifest and comply with other state regulations as appropriate. <br /> COMPANY NAME: fA Vm i r)q t un FyyoA COMPANY REP: 7bnq ' f fl tkM1.C(A' <br /> COMPANYADDRE5S: e uwyq q9 fi*V-yl g4a EPA I )tf: <br /> CITY, STATE, ZIP : f�VWTO CA6.�j2, 1. 5 SIGNATURE: <br /> COMPANY PHONE: (20q ) q( '`,J-'�11 0 n TITLE: DATE: <br /> TO BE COMPLETED BY STERICYCLE CHECK-IN ATTENDANT <br /> GENERAL WASTE DESCRIPTION HAZARD All STATE S/ N OF CONTAINER WASTE WT(LO) DISK COST <br /> j (04EMICAL CONS'IT1118NT, Pb�EjCL CLASS WASTE - CODE L CONT ; I YNt/SizE . AMOUNTMlil'fi <br /> T=1 t toY� C�r1 F is tA4N , Z2 4( , ` • . fa0 <br /> *+ Cc > � <br /> o 1 (Aw ' zr 1: z� <br /> P�u�t 9's (,vvv ZsS <br /> P fasts �� t� ab <br /> l n <br /> METHOD OF PAYMENT: CASH ❑ CHECK CI CHECK NO. TOTAL PAID $ SO! 7.5' <br /> STER.ICYCLE CHECKIN ATTENDANTS INITIALS DATE <br /> Psc.207 aevans ...';, .:CHECK IN RECEIPT <br />