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RECEIVED <br /> 11855 White Rock Rd . <br /> i *4 S tr $ c Rancho Cordova, CA 95742 Date : 7/2/202 <br /> t916j 351-0980 <br /> % L 00 2 "2 <br /> I: IN' i' II ONINILidrm 1IEAUrll <br /> Time : 8 : 15 AW)' kwrNrIENT <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 Stericycie 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 /> I 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 /> Ito exceed small quantity limits or contain materials not accepted under this program I agree to complete a hazardous waste manifest and comply with other <br /> state regulations as appropriate. <br /> Company Name , Food4Less Company Rep : Jesus Jurado . <br /> Company Address : 3434 Manthey Road EPA ID # ~- .- CAL 000 423 137 <br /> Stockton, CA 95206 Signature . <br /> Phone Number ; 209=9924463 Title ,* Compliance M nager `Date : 7/2/2020 <br /> TO BE COMPLETED BY STERICYCLE CHECK-IN ATTENDANT <br /> General Waste Description (Chemical Haz. AH State - # of Container Total Waste Total Waste Disp <br /> Constituent, Ph, WTC.) Class Waste Code SQL Cont. Type/Size (gal / ft) ( pounds) Meth COSI <br /> Absorbent W/ Cleaners NR S 120 lbs $ 168 . 00 <br /> - <br /> i . <br /> Processing Fee $ 20 . 00 <br /> Method of P.ymnt: Cash Check# Inv r t' Total Paid : $ 188 .00 <br /> Stericycle Check- ln Attendants Initials; . F t Date: <br />