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6`c 118')5 WHt H' ROCK ROAf7 <br /> 6 -Steric c_ e' f c. f7ace.of f: r.nc <br /> ep © [Zl�NCNC3 f C)fif. OVA, CA 1574'?_ ["iitie T <br /> (916).35f-0990 <br /> Finic5 t'artiripau.d. <br /> CONDMONALLY EXEMPT SMALL QUANVTV GENERATOR WASTE <br /> CHECK-IN RECEIPT AND CT<RTfF(CATION STATEMENT <br /> TO )v3E C4MFLETCD BY GENERATOR;ry�' _._._.._..�.�..�. <br /> I certify that the following ixtformation is correct, and L have read.and understalt.d the requirements for participation in the <br /> �tcricycte Conditionally Exempt Small Quantity Generator Waste Acceptance Program, L further certify that(ani.a Conditionally Exempt <br /> )tmtl Quantity Generator as def"i"ned by Federal and California State regulations, and this quantity of waste does not exceed the spcciEed <br /> imits for the type of waste being disposed. t'f this waste is later found to exceed stoat(quantity liruits or contain materials not accepted <br /> ander this program,T agree to complete a hazardous Waste manifest and cotnpty with other state regulations as appropriate. <br /> 7OMPA.NY NAME: AMU WW,f[ — 7 COMPANY REP. 004-0A <br /> ,OMPANYADDRESS-- � EPArnt#: <br /> '[TY, STATE,zrr SrGNA"1'CIRE: <br /> 'OMPAt�iY PffONE- T,ITr.E: DA'T'E, <br /> TO BE COMPLETED BY STER-1CYCLE caECK-w ATTENDANT <br /> G13NEM WASTE AESCRTE'TION . HAZARU AH STATE S/ #OF WrAT1�M WASTE WT[X) DIS>r ST <br /> TWWC .0M.WASTE. E•1rC. CLASS WASTE CODE L CONT T'YPE/SaR AMOUNT METE[ <br /> • E <br /> I <br /> • I <br /> i <br /> :rTHOD O .PAYMENT: CASH ❑ CHECK Q CHECK NO. TOTAL VAIi V <br /> ERI:CYCLE CHECK-TN ATTENDANTS NITL LS_ DATE <br /> .an? REVQVis CRSCKJN REC;E[PT <br /> r <br />