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11855 White Rock Rd. <br /> ; Ja >•p Rancho Cordova, CA 95742 <br /> ra�° Date: 11/20/2019 <br /> (916) 351-0980 <br /> Time: 8:30 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 5tericycle 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 later found <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: Centrisys Corporation Company Rep: Ryan Dowdell <br /> Company Address: 825 Performance Drive EPA ID# CAL 000 333 333 <br /> Stockton, CA 95206 Signature: <br /> Phone Number: 262-764-8712 Title- {�� Date: r� <br /> TO BE COMPLETED BY STERICYCLE CHECK-IN ATTENDANT <br /> General Waste Description(Chemical Haz. AH State #of Container Total Waste Total Waste Dlsp <br /> I Constituent,Ph,WTC.) Class waste Code Sal Cont. Type/Size (gal/ft) (pounds) Meth COSI <br /> Motor Oil NR L 1 55 gal 55 gal $11.00 <br /> Sand Blasting Media NR S 3 5 gal 75 lbs $105.00 <br /> p Motor Oil Filters NR S 1 5 gal (7 Each) 10 lbs N/C <br /> Steel Shavings 6.1 S 1 5 gal 7 lbs $9.80 <br /> Oil Sorbent NR S 1 5 gal 11 lbs $15.40 <br /> t <br /> i <br /> Processing Fee $20.00 <br /> Method of Pymnt: Cash Check# Inv [9 Ci Total Paid.• $161.20 <br /> Stericycle Check-In Attendants Initials: Date: fir_ •ter <br />