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i'B r z 11853 White Rock Rd . <br /> 11 S ri l Rancho Cordova CA 9.5742 Date: 1/812020. <br /> + �d <br /> (916.)-551-0980- <br /> f r v rc)mwKi18'i int iatVI!; <br /> Tl me: 8.45 AM <br /> CONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR WASTE .HEMIN AND CERTIFICATION <br /> RECEIPT AND CERTIFICATION STATEMENT <br /> To be completed by the generator,_ _ <br /> i certify that the folloWing information is correct, apdj have read-and understand the requiremerit6 for participation in the Sterlcycle Conditionally Ekemo <br /> Small Quan4ftyGeneratorWaste AcceptanceProgram, lfurthercertify,thadfama "Cond onally€xemptsmall:q,uarvbtyGeneratorasdefinedbyFederal.and <br /> California Stote,Reguipvqns, aod this quahtityof wostedoes not exceed S1ie sperlfied,l mlts for the*e o£ waste being disposed. if this'waste is later found <br /> to exceed small gyartti{y limier§or contain rmaterials notaccepted undertins prograt l agree-'ko uJ'mplete a hazardous Waste, manl£estond comply with, <br /> dther.state reguiatims as.appropnate., <br /> Company Name: Oplons ETC:: Company Rep Tony Murgull <br /> a <br /> Company Address;: 1003-C Humphreys Drive EPA 04 CAL 000 451 ,633 <br /> Stockton, CA195203 S[ nature : <br /> Phdne Number; 209-327-8399 Title: Date : <br /> TO BE COMPLETED BY:STERICYCLE CHECK-IN ATTENDANT <br /> General Waste Description (Chemical Haz, AK State 3/t k of �Contelner Total Waste Totaf Waste Disp. Cost <br /> Constituent,, Ph, WPMC Class Waste- ,Code eo,nG 'Type/size - lgal / f'ti. {pounds,9 Meth-' <br /> 4' Fluorescent Bulbs uW S 174, ' ,Boxed 696' $104:40 <br /> 8' Fluorescent, Bull s- UVJ S 17 Boxed. 136' $20.40 <br /> Metal Hal➢de Buba' UVJ 5 34 Boxed 25 Ibs $75:00 <br /> Non-PCB Ballasfis NR 5: 15 Each 38 lbs $30.49. <br /> Hydraulic C10 NR. L 5 S gal 25 gal $87 .50 <br /> Processing Fee $ 20 :00 <br /> Method of Pyfnnt: cash Check# 2Y2L Inv Total Paid: $337.:70 <br /> Steeicyde Check-In Attendants Initlals: L g , Date: <br />