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F;+ stericycle` <br />11855 White Rock Rd, <br />Rancho Cordova, CA 95742 <br />(916) 351.0980 <br />Date: 8/14/2019 <br />Time; 9:00 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 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 <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: Girolami Farms <br />�.��nNai�y Haaress: <br />Phone Number; <br />General Waste Description (Chemical <br />Constituent, Ph, WII <br />Contam, Soil W/Hydraulic Fluid <br />7.1502 E. Eight Mile Rd. <br />Stockton, CA 95212 <br />Company Rep: <br />Signature: <br />Grant Girnlami <br />CAL 000 413 561 <br />209-887-5015 <br />Title:r ,� Date: r <br />TO BE COMPLETED BY STERICYCLE CHECK-IN ATTENDANT <br />Naz, AH State #t of Container Total Waste Total Waste Disp <br />Class Waste Code S/! <br />Cont. Type/Size (gal / ft) (pounds) Meth <br />Processing Fee <br />Method of Pymnt; Cash COSI <br />Check# <br />>tericycle CheckIn Attendants Initials: <br />1 ( � <br />Inv _ Total Paid: <br />Date: <br />S 5 gal � 46 lbs <br />$ 64.40 <br />$20.00 <br />$84,40 <br />