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t <br /> 11855 White Rock Rd. <br /> s..'s Stericyck Rancho Cordova, CA 95742 Date: 9/11/2019 <br /> (916) 351-0980 <br /> "riyt{t��rxetlS.G�3:`•tii'�:3.4%5{',:� <br /> Time: 9:45 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 /> other state regulations as appropriate. <br /> Company Name: Pactiv Company Rep: Al Yado <br /> Company Address: 4545 Qantas Lane EPA ID# CAL 000 377 286 <br /> Stockton, CA 95206 Signature: <br /> Phone Number: 209-983-3140 Title: 9,"'/yDate: /9 <br /> TO BE COMPLETED BY STERICYCLE CHECK-IN ATTENDANT <br /> General Waste Description(Chemical Haz. AH State S/L #of Container Total Waste Total Waste. Disp Cost <br /> Constituent,Ph,WTC,) Class Waste Code Cont. Type/Size (gal/ft) (pounds) Meth <br /> Oily Debris/Absorbent NR S 1 Bag 25 lbs $35.00 <br /> Processing Fee $20.00 <br /> Method of Pymnt: Cash Check# Inv C C' Total Paid: $55.00 <br /> Stericycle Check-in Attendants Initials: Date: <br /> _. .... . .. ............ <br />