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I�� <br /> .` Sterrcycles 118!i5 White Rock Rd. 6/26/2019 <br /> Rancho Cordova,CA 95742 Date: <br /> (916)351-0980 <br /> Cnyx�nn��ai Soil;i��sa <br /> Time: 11:00 AM <br /> CONDITIONALLY L-X;r!1PT SMAI <br /> RECEIPT ANDCERTIFICATION STATEMENTWASTE <br /> CHECK-IN AND CERTIFICATION <br /> To be completed by the generator: <br /> I certify ttiat the following information is correct,and i have read and understand the requirements for participation in the Stericycle Conoitionally Exempt <br /> small Quantity Generator Waste Acceptance Program,1 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 waste being disposed.If this waste is later found <br /> to exceed small quantity limits or contain materials notaccepted tate regu adore as appropriate. <br /> gram Iagrr <br /> accepecomplete <br /> e a hazardous waste manifest and comply with <br /> Bobby Atwal <br /> Company Name: USA Auto Plaza and Car Wash inc Company Rep: CAL 000 445 39 <br /> 5121 Holida <br /> Company Address: Y Dr. EPA ID# <br /> Stockton,CA 95207 Signature: <br /> Phone Number: 209-627-6960 <br /> Title: /IDate: <br /> To BE COMPLETED BY STERiCYCLE CHECK-IN ATTE DANT <br /> #of container Total Waste Total Waste Usp Cost <br /> General Waste Description(Chemical Haz. AH State Sit Cont. Type/Size (gal I ft) ,pounds) Maul <br /> Constituent,Ph,WTC.) Class waste Code N/C <br /> Used Motor if 1%R L 5 5 gal 25 gal $52.50 <br /> oil/Water Mixture FJR L 3 5 gal 15 gat <br /> T $2t <br /> Processing Fee - Total Paid: <br /> Method of pymnt: Cash Check# Date: <br /> �tericvcle Check-In Attendants Initials: --------- <br />