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4' 11855 White Rock Rd . <br /> 06 �tencycle Rancho Cordova, GA 9574 Date : 5/22/2019 <br /> a <br /> (915) 351-0980 <br /> r,.yar��e~��rti�l3 flfii�ns <br /> Time : 8 : 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 forthe 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 hazardaus waste manifest and comply with <br /> other state regulations as appropriate. <br /> Company Name : Historical Society Museum Company Rep : Rigoberto Ruiz <br /> Company Address : 11793 N Micke Grove Wy . EPA ID # C 000191372 <br /> Lodi, CA 95240 Signature : <br /> Phone Number : 209-993 -3043 Title ; Al �&)kcJ Date : <br /> TO BE COMPLETED BY STERICYCLE CHECK-IN ATTENDANr5Cy �t 'V <br /> General Waste Description (Chemical Haz. AH State # of Container Total Waste Total Waste Disp <br /> Constituent, Ph, WTC.) Class Waste Code S/ L Cont, Type/Size (gal / ft) (pounds) Meth COSI <br /> Paint 3 L 25 1 gal 25 gal $ 87 . 50 <br /> Paint 3 L 8 1 cit 2 gal $ 7600 <br /> Processing Fee $20. 00 <br /> Method of Pymnt: Cash Check# Inv Total Paid : $ 114. 50 <br /> Stericycle Check-In Attendants Initials : , Date : <br /> i\11 AY 2 2019 <br /> EN v PRONMENTA,L HEA Ti • ?0021r;z <br /> T' <br /> pEPARTMEN •: R~vorrc�pE�puiGix-- - - <br />