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r�* <br /> Stericycle' 11855 White Rock Rd. <br /> Rancho Cordova,CA 95742 Date: 8/14/2019 <br /> (916) 3S1-0980 <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 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 Kosko <br /> Company Address: 240 W. Freemont Street 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. FATHtate SQL #of Container Total Waste Total Waste Dlsp Cost <br /> Constituent,Ph,WTC.) classde Cont. Type/Size (gal/k) (pounds) Meth <br /> Metal Halide Bulbs UW S 12 Boxes 44.92 lbs $134.76 <br /> CFLs UW S 76 Each 11.62 lbs $34.86 <br /> Fluorescent Bulbs UW S 4 Boxes 2,214' $332.10 <br /> Alkaline Batteries UW S 1 Box 44.95 lbs $31.46 <br /> Sealed Lead Acid Batteries UW S 17 Boxes 113 lbs $169.50 <br /> Processing Fee $20.00 <br /> Method of Pymnt: Cash Check# Inv Total Paid: $722.68 <br /> Stericycle Check-in Attendants Initials: Date: <br />