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11855 White Rock Rd. <br /> bterlcycle4 <br /> Rancho Cordova, CA 95742 <br /> (916) 353-0980 Date: I /2019 <br /> Time: q:00 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 <br /> otherstate regulations as appropriate. <br /> Company Name: Hernandez Auto Body& Paint Company Re <br /> P y p: Raul Hernandez <br /> Company Address: 840 E.Jefferson St. EFA 1D# <br /> A!f' 00361175 <br /> Stockton, CA 95206 Sig�tue: <br /> Phone Number: <br /> 209-981-6956 Title: o Date: / <br /> TO BE COMPLETED BY STERICYCLE CHECK-IN ATTENDANT <br /> General Waste Description(Chemical Haz. AH State #of Container Total Waste Total Waste <br /> S/L Diso <br /> Constituent,Ph,WTC.) class Waste Code Cont. Type/Size (gal/ft) CO$t <br /> (pounds) Meth <br /> !Laquer Thinner(empty) 3 ! 15 5 gal <br /> processing Fee <br /> a $20.00 <br /> lethod of Pymnt: Cash Check# ` <br /> Inv Total Paid: $ <br /> teri.F, e Check-In Attendants Initials: I jDate- <br /> 1 -791 <br /> ate_ <br /> - 1 -7 9 1 - ----r— <br /> CREDIT CfiRD ENDDI6 Iii <br /> 3 <br />