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11855 White Rock Rd. <br /> Sterelcycle Rancho Cordova,CA 95742 Date: 9/4/2019 <br /> (916)351-0980 <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 for the type of waste being disposed,if this waste is laterfound <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,Inc. Company Rep: Rocky Myers <br /> Company Address: 1012 S. Acacia Avenue EPA ID# CAL 000 296 071 <br /> Ripon, CA 95366 Signature: ^_ <br /> Phone Number: 209-599-8788 <br /> TO BE COMPLETED BY STERICYCLE CHECK-IN ATTENDANT <br /> General Waste Description(Chemical Naz. AH State S�� #of Container Total Waste Total Waste DisP Cost <br /> Constituent,Ph,WTC.) Class Waste Code Cont. Type/Size (gal/ft) (pounds) <br /> PVC Pipe Cement 3 L 27 1 gal 27 gal th $94.50 <br /> $20.00 <br /> Processing Fee <br /> Method of Pymnt: Cash Check# <br /> Inv Total Paid: $114.50 <br /> Stericycle Check-In Attendants Initials: Date: <br /> cxEnrr cAxriEND <br /> mr <br />