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;# <br /> btericycw 11855 White Rock Rd. <br /> Rancho Cordova, CA 95742 <br /> •"•ytr (916) 351-0980 Date: 5/15/2019 <br /> CONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR wgsTme: 9:00 AM <br /> RECEIPT AND CERTIFICATION STATEMENT <br /> CHECK-IN AND CERTIFICATION <br /> To be completed by the generator: <br /> 1 certify that the following information is correct,and I have read and understand the requirements for participation in <br /> Small Quantity Generator Waste Acceptance Program,!further certify that!am a Conditionally Exempt small <br /> California State Regulations,and this quantity o{waste does not exceed the spocified limits for the type of waste bein the Stericycle Conditionally Exempt <br /> to exceed small quantity limits or contain materials not accepted under this program I agree to complete ahazardous waste manifest and comply with <br /> Company Name: appropriate, <br /> Hernandez Auto Body& Paint <br /> Company Address: 840 E. Jefferson St. Company Rep: Raul Hernandez <br /> Stockton, _A9 206 EPA ID # AL,,000 361 175 <br /> Phone Number: Signature: <br /> 209-981-6955 _ <br /> Title: ,✓.gid �C: Date, <br /> TO BE COMPLETE® BY STERICYCLE CHECK-IN ATTENDANT ® <br /> General Waste Description(Chemical Haz. AH State <br /> S/L #of Container Total Waste Total Waste <br /> Class Waste Code Cont, Type/Size Disp <br /> Constituent,Ph,WTC.) <br /> Laquer Thinner(empty) 3 {gal/ftl (pounds) Meth Cost <br /> L 15 5 gal -- <br /> 'rocessing Fee <br /> lethod of Pymnt: Cash $20.00 <br /> Ch@ck# Inv <br /> teri_r, e Check-In Attendants initials: Total paid.- $ 10 <br /> CREDIT CARD ENDING IN <br /> r <br />