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"L 13855 White Rock Rd. <br /> „ 'J k n yfe", <br /> P, Rancho Cordova, CA 95742 Date: <br /> (915) 351-0980 <br /> 1 <br /> CONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR WASTE CHECK-1N AND CERT!F1 CATI ON <br /> RECEIPT AND CER T IEICA T iON STATEMENT <br /> To be completed by the generator: <br /> I certify that the toilowing information is correct,and I have read and understand the requirements for participation in the 5tericycle ConditionaI[y Exempt <br /> 5mail Quantity Generator lNaste Acceptance Program.I further certify that€am a Conditionally Exempt Small Quantity Generator as defined by Federal and <br /> Califomia State Regulations,anti this quantity of waste does not e5cceed the specified limits for the type of waste loping disposed.If this v.,aste is later found <br /> to exceed small quantity limits or contain materials not accepted under this program 1 agree to complete a hazardous waste manifest and comply with <br /> other state regulations as appropriate. <br /> Company Name: Masco Electric Sion Company,int. Company Rep: Pam Lindsey <br /> Company Address: 31801'N� Ad Art Road EPA !D A CAL O'00 290 917 <br /> Stockton, CA 95215 Signatur : VI f a <br /> Phone Number: 209-931-1924 Title' 04- 0A te- <br /> TO BE COMPLETED BY STERICYCLE CHECK-IN ATTENUANT <br /> General Waste oescripiion(Chemical Haz. AX State {pounds}N of Container Total YL+aStC Total ,taste ro's=p <br /> iVeih <br /> Constituent,Ph,WTC.} Class waste Code SA Cont, -1yoe/Size lgal!-1-0l Cast <br /> Contaminated Motor ail NR L 1 55 55 gal $410.00 <br /> rimable Liquid - 3 i L 1 25 25 gal 587.50 <br /> MASCO ELECTRIC SIGN CO.,INC. 10767 <br /> Stericycle Environmental Solutions 111612019 <br /> 455.50 <br /> 1002 Bank of Stockto 455.50 <br /> � II 111 I l I I illllll�Il i <br /> 1005:1M01511 675 n5(&15) 100591 Rev 211.1 <br /> ❑.o.-oryyrnn�: ash Cherk4 Inv — Total Paid: $455.50 <br /> 5tericycle Check-In Attendants lnitials: Date: <br />