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11855 White Rock Rd. <br /> CleanEafth Rancho Cordova, CA 95742 Date: 9/2/2020 <br /> (916) 351-0980 <br /> Time: 8:45 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 other <br /> state regulations as appropriate. dcrawford@asmstockton.com <br /> Company Name: ASM STOCKTON Company Rep: David Crawford <br /> Company Address: 248 W. Fremont St. EPA ID# CAL 000 377 711 <br /> Stockton, CA 95203 Signature: <br /> Phone Number: 209-373-1400 Title: Ops MGR Date: <br /> TO BE COMPLETED BY STERICYCLE CHECK-IN ATTENDANT <br /> General Waste Description(Chemical Haz. AH State S/L #of Container Total Waste Total Waste Disp Cost <br /> Constituent,Ph,WTC.) Class Waste Code Cont. Type/Size (gal ft) (pounds) Meth <br /> Alkaline Batteries UW S 1 Bucket 60 lbs $42.00 <br /> 4' Fluoresent UW S 1 Barrel 1440' $216.00 <br /> 8' Fluoresent UW S 2 Box 232' $34.80 <br /> CFL (14.4 lbs Broken) UW S 4 Box 19.5 lbs $32.17 <br /> Metal Halide (6.8 lbs broken) UW S 9 Box 35.8 $107.40 <br /> Empty 55 Gallon Drums NR S 6 $66.00 <br /> Processing Fee $20.00 <br /> Method of Pymnt: Cash Check# Inv Total Paid: $518.37 <br /> Stericycle Check-In Attendants Initials: Date: <br />