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� 11855 White Bock Rd, <br /> 5tericycle Rancho Cordova,CA 95742 Date: 7/19/2013 <br /> (916) 351-0980 <br /> x <br /> i1no-tw,tenO <br /> solvwns <br /> Time: 8:30 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.l 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 underthis program I agree to complete a hazardous waste manifest and comply with <br /> other state regulations as appropriate. <br /> Company Name: Allen A. Waggoner Construction Company Rep: Rocky Myers <br /> Company Address: 1012 S.Acacia Avenue EPA ID# CAL 000 296 071 <br /> Ripon, CA 95366 Si ture: <br /> Phone Number: 209-599-8788 TitEF2�� <br /> le: " Date: l? <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 D;sp Cost <br /> Constituent,Ph,WTC.) Class waste Code Cont. Type/size (gal f ft) (pounds) Meth <br /> CCH Tablets 5.1 S 31 5 Ib 155 Ibs $286.75 <br /> Purple Primer 3 L 10 1 gat 10 gal $35.00 <br /> .�f <br /> $20.00 <br /> Processing Fee <br /> Method of Pymnt: Cash Check# ���I� Inv <br /> Total Paid: $341.75 <br /> stericycle Check-in Attendants Initials: /4 Date' <br />