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11855 White Rock Rd. <br /> Stericycle Rancho Cordova, CA 95742 <br /> Date: 9/4/2019 <br /> (916) 351-0980 <br /> Time: 830 AM <br /> CONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR WASTE CHECK-IIS 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 5tericycle Conditlonally 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.[agree to complete a hazardous waste manifest and comply with <br /> other state regulations.as appropriate. <br /> Company Name: Arrow Sign Company Company Rep: Ruth Lopez. <br /> Company Address: 3133 N. Ad Art Road EPA ID # CAL 000 275 331 <br /> Stockton, CA 95215 Signature: <br /> Phone.Number: 209-93.1-5522 Title <br /> Date-9L , <br /> TO BE COMPLETED BY STERICYCLECHECK.Ill ATTENDANT <br /> General Waste Description(Chemical Haz. AH State SQL of Container Total Waste Totat Waste oisp <br /> Constituent,Ph,WTC.) Class Waste Code Cont, Type/Size (gal ft) (pounds) Meth Cost <br /> Waste rags with Acetone NR S 1 3.0 gal 125 lbs $175.00 <br /> Processing Fee $20.00 <br /> Method of Pymnt: Cash Check# Inv .-� Total Paid: $195;00 <br /> Stericycle Check-in Attendants Initials: Date: I CA <br /> ~�err CARD Exn <br />