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11855 White Rock Rd. <br /> Rancho Cordova, CA 95742 Date: /;2D <br /> CleanEafth <br /> (916) 351-0980 <br /> Time: <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 Stericycle 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 to <br /> exceed small quantity limits or contain materials not accepted under this program I agree to complete a hazardous waste manifest and comply with other <br /> state regulations as appropriate. <br /> Company Name: oo Company Rep: <br /> Company Address: r EPA ID # <br /> Signature: <br /> Phone Number: to CA <br /> Title: W e: :71 'Z <br /> TO BE COMPLETED BY STERICYCLE CHECK-IN ATTENDANT <br /> General Waste Description(Chemical Haz. AH State #of Container Total Waste Total Waste Disp <br /> Constituent, Ph,WTC.) Class Waste Code SQL Cont. Type/Size (gal ft) (pounds) Meth COSI <br /> Processing Fee $20.00 <br /> Method of Pymnt Cas Check# Inv Total Paid: $ ®� <br /> Stericycle Check-In endants Initials: Date: �� ,p <br />