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� Yde11855 White Rock Rd . <br /> rSteric Rancho Cordova , CA 95742 Date : 10/23/2019 <br /> ( 916) 351-0980 <br /> Time : 10 : 45 AM <br /> CONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR WASTE CHECK- IN AND CERTIFICATION <br /> RECEIPT AND CERTIFICATION STATEMENT <br /> To 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 . Lodi Memorial Cemetary Company Rep : lose Buzo <br /> Company Address : 5750 E . Pine Street EPA ID # CAL 000 335 665 <br /> Lodi , CA 95240 Signature : <br /> Phone Number : 209- 294 - 3390 Title : Date : <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 COSI <br /> Constituent, Ph , WTC. ) Class Waste Code Cont . Type/Size (gal / ft) ( pounds ) Meth <br /> 4 ' Fluorescent Bulbs UW S 1 Box 40 ' $ 6 . 00 <br /> Alkaline Batteries UW S 1 1 QT 3 lbs $ 2 . 10 <br /> Oil Rags NR S 1 5 gal 5 lbs $ 7 .00 <br /> Oily , Saw Dust NR S 1 5 gal 10 lbs $ 14 . 00 <br /> Processing Fee $ 20 . 00 <br /> Method of Pymnt : Cash Check# Inv Total Paid : $ 49 . 10 <br /> Stericycle Check- In Attendants Initials : Date : <br /> I <br /> I <br />