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11855 White Rock Rd. <br /> Stericycle Rancho Cordova, CA 95742 Date: 9/5/2018 <br /> I . (916) 351-0980 <br /> cI '� <br /> Time: 8:15 AM <br /> CONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR WASTE CHECK-IN AND CERTIFICATION <br /> RECEIPT AND CERTIFICATION STATEMENT <br /> To be completed by the generator: J <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: SMG Stockton Company Rep: Hank Kasko <br /> Company Address: 240 W Fremont St. EPA ID # N/A <br /> Stockton, CA 95203 Signature: <br /> Phone Number: 209-606-2410 Title: Date: <br /> TO BE COMPLETED BY STERICYCLE CHECK-IN ATTENDANT <br /> General Waste Description(Chemical Haz. AH State H of Container Total Waste Total Waste Disp <br /> Constituent,Ph,WTC.) Class Waste Code SfL Cont. Type/Size (gal/ft) (pounds) Meth COSI <br /> Metal Halide Bulbs UW S 22 95.06 $285.18 <br /> Metal Halide Bulbs Broken UW S 1 5.34 $16.02 <br /> CFL UW S 7 119.08 $148.85 <br /> CFL Broken UW S 2 61 $100.65 <br /> Fluorescent Bulbs UW S 23 4558' $683.70 <br /> Fluorescent Bulbs Broken UW S 4 48.5 $80,25 <br /> Alkaline Batteries UW S 3 229.1 $160.37 <br /> Processing Fee $20.00 <br /> Method of Pymnt: Cash Check#; Inv Total Paid: $14q 115.02. <br /> Stericycle Check-In Attendants Initials: Date: <br />