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Stericycle <br /> 11855whEte Rock Ad,Rancho Cordova, C4 95742 Date:: '9/4/2019 <br /> (916) 3510980 <br /> Time 8:30 AM <br /> CONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR WASTE CHECK-IN AND CERTIFICATION <br /> RECEIPT ANO CERTIFICATION STATEMENT' <br /> To be completed by the generator: <br /> I certifythat the foflowintinformation is correct,and I have read and underst'a'nd the requirements for participation In the stoficycie Conditlo0aliy exempt <br /> Sniall quantity Getreratar Waste Acceptance Program,I further certlfy that i am a Conditionally Exempt Small quantity Generator a$d0ned-by Federal and <br /> Calffbinla State Reguiatlons,andthis quant.4 of waste does not exceed the speclfied IWR4 for the type of waste:being disposed,If thls.wasta'GS later found <br /> -to exceed srnafl quantity limits,or contain materlals not accepted under this program I agree to oomplete a hoardous waster manifest and cemply with <br /> ether state regulations-as'appropriate, <br /> Company Dame: Arrow Sign Company Company Rep: Rtath Lopez <br /> Company Address: 3133 N, Ad Art Road EPA ID# CAL 000 175 331 <br /> Stockton, CA 95215 Signature: <br /> Phone INumbor: 209-93.1.5522 Title:. <br /> TO BiE'COMPLETED BY 5TERICYCLE CHECK-114 ATTENDAN-r <br /> General WasteNscriptlan(Ehemleal Hai, AH State Sal p of container Tow waste `Total Woste Disp <br /> Constlt4ent,Ph,WTJO class waste Code cont, Type/siie (gal I ft) (pounds) Meth. Cost <br /> Waste rags with Acetone NR 5 1 3.0 gal 125 lbs. $175.00 <br /> i <br /> i <br /> l <br /> i <br /> i <br /> s <br /> • T <br /> Processing Fee $2Q,00 <br /> Method of Pymnt: cash Check# Inv/ Total Paid: $193,00 <br /> Ste-rlcycle Check-tn Attendants Initials: Date; <br /> CAN i <br />