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Received on 1025/2019 <br /> �rC�C�@z 11655 White Rock Rd. SJC EHD - CR <br /> I <br /> �! t Rancho Cordova,CA 95742 Date: 10/25/2019 <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 fallowing information Is correct,and I have read area understand the requirements for participation in the Stedcycie Conditionally Exempt <br /> Small quantityGenerator Wane AcceptareeProgram.I further certify that I am a ConotionallyExemptSmall civanthy Gene ratoras defined by federal and <br /> CarfOrnia Stale 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 matedals not accepted under this program I agree to camplete a hazardous waste manifest and comply with <br /> other state regulations as appropriate. <br /> Company Name: AM. Farms Company Rep: Mamie Bellini <br /> Company Address: 9010 Howard Rd, EPA ID# L 0092081 <br /> Stockton,CA 95206 Signature: " <br /> Phone Number: 209-462-1185 Title: ate: <br /> TO BE COMPLETED BY STERICYCLE CHECK-IN ATTENDANT <br /> General waste Description(Chemical Her. AH State Of Container Total Waste Total Waste Dlsp <br /> Constituent,Ph,WTC.) Class waste Code S/l Cant. TypeISIN (R-1/11) (pounds) Meth Cost <br /> Dirt w/Oil NR 5 4 Buckets 401155 $56.00 <br /> (missed ballasts) NR 5 15 Each {Paid) <br /> Processing Fee - $20.00 <br /> Method of Pymnt: Cash Check# /w Inv ITotal Paid: $76.00 <br /> Stericirde Check-in Attendants Initials: ,�� Date: <br />