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11855 White Rock Rd. <br /> tele 5 te * rtycle" Rancho Cordova,CA 95742 ©ate: 8/7/2019 <br /> (916) 351-0980 <br /> Time: 8:45 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 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: Allen A.Waggoner Construction Company Rep: Rocky Myers <br /> Company Address: 1012 S.Acadia Avenue EPA ID# CAL 000 296 071 <br /> Ripon, CA 95366 Si nature: <br /> Phone Number: 209-599-8788 Title:hekI,' ate: 4ni <br /> TO BE COMPLETED BY STERICYCLE CHECK-IN ATTENDANT C <br /> General Waste Description(Chemical Haz. AH State SIL #of Container Total Waste Total Waste D;sp Cost <br /> Constituent,Ph,WTC.) Class Waste Code Cont. Type/Size {gal J ft} (pounds) Meth <br /> Purple Primer 3 L 8 1 gal 8 gal $28.00 <br /> Gray PVC Pipe Cement 3 1 L 1 20 1 gal 20 gal $70.00 <br /> Processing Fee $20.00 <br /> Method of Pymnt: Cash Check# €- Inv Total Paid: $518.00 <br /> Stericy he Attendants Initials: Date: <br /> '; 'CRF-DIT CARD ENDING IN <br />