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11155 White Rock Rd. <br /> I.N.", Stericyde� Rancho Cordova, CA 95742 Date: 10/30/2019 <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.Acacia Avenue EPA ID# ---2 CAL 000 296 071 <br /> Ripon, CA 95366 Sjgijature:,,,4K�r1w A fhMeL j <br /> pk7? <br /> Phone Number: 209-599-8788 Title: ja�e <br /> TO BE COMPLETED BY STERICYCLE CHECK-IN ATTENDANT 7- <br /> General Waste Description(Chemical Haz. AH State S/L of Container Total Waste Total Waste Disp Cost <br /> Constituent,Ph,WTC.) Class waste Code Cont. Type/Size (gal/ft) (pounds) Meth <br /> PVC Pipe Cement 3 L 13 1 gal 13 gal $45.50 <br /> Processing Fee .17 1 $20.00 <br /> Method of Pymnt: Cash Check#.,, — Inv ITotal Paid: $65.-50 <br /> Stericycle Check-in Attendants Initials: A Date: <br />