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0 71 11855 White Rock Rd . <br /> StencycleRancho Cordova , CA 95742 Date : 1 / 15 / 2020 <br /> a <br /> ( 916 ) 351 - 0980 <br /> . � � . .16 1 11 <br /> Time : 9 : 00 AM <br /> ONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR WASTE CHECK - IN AND CERTIFICATION <br /> ry <br /> RECEIPT AND CERTIFICATION STATEMENT <br /> To be completed by the generator : <br /> rtify that the following information is correct, and I have read and understand the requirements for participation In the Stericycle Conditionally Exempt <br /> ill Quantity Generator Waste Acceptance Program . I further certify that I am a Conditionally Exempt Small Quantity Generator as defined by Federal and <br /> fornia 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 /> exceed small quantity limits or contain materials not accepted under this program I agree to complete a hazardous waste manifest and comply with <br /> other state regulations as appropriate . <br /> mpany Name : California Autosport Company Rep : Dorian Dugish <br /> mpany Address : 180 Button Avenue EPA ID # CAL 000 430 494 <br /> Manteca , CA 95336 Signature : <br /> one Number : 209 - 665 - 7247 Title : Date : <br /> TO BE COMPLETED BY STERICYCLE CHECK - IN ATTENDANT <br /> neral Waste Description ( Chemical Haz . AH StateSit # of Container Total Waste Total Waste Dlsp Cost <br /> Constituent, Ph , WTC . ) Class Waste Code Cont . Type/Size (gal / ft ) ( pounds ) Meth <br /> 3ke Shavings 6 . 1 S 1 5 gal 20 lbs $ 28 . 00 <br /> ocessing Fee $ 20 . 00 <br /> ethod of Pymnt : Cash Check# Inv Total Paid : $ 48 . 00 <br /> . ericycle Check- In Attendants Initials : Date : <br />