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*,vol Rancho Cordova,CA 95742 [late.. 2/6/2019 <br /> (9161351-0980 <br /> ±rim¢ <br /> Time: 8:15 AM- <br /> CONDITIONALLY-EXEMPT SMALL QUANTITY GENERATOR WASTE CHECK-IN AND CERTIFICATION <br /> RECEIPT AND.CERTIFICATION STATEMENT <br /> Io be completed by the generator <br /> 1.cer+rythatthefoila ving information:is-correct and 1 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 Candhianally Exempt Small quantity Generator as defined by.Federal and <br /> -C-aiifomiaSrtate-Regulations,and this quantity of waste does nut 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 is agreeAQ-complete a hazaardous waste manifest and complywith <br /> other state regutations asappropriate <br /> Company..Name- moctezum&'s.Auto Dismantling&Auto Company"Rep_ Antonio <br /> Company Address: 1679 5 Orion St. EPA ID# 1?—�CAL 000.427-06,9 <br /> Stockton CA 952€6 Signature: Wk <br /> -Phone Number -203252-8118 Title:. ( Date:- L —C —� <br /> TO BE COMPLETED BY STERICVCLE CHECK-IN ATTENDANT <br /> 'General waste Description{Chemical Haz AH 'State ,.-V1 4 of container Total Waste Total Waste Disp Cost <br /> Constituent,Ph,WF.C) - Class Wage eGode -cont. Tyw5ize (gal¢ft) (pounds) Meth <br /> Paint(oil based) 3 L 3 5 gal 15 $52.50 <br /> Mixed-Motor Ortlj Antifreeze NR- L 1. 5 gat 5 $41.25 <br /> Empty'Cras-Container IVR S 1 10 gal I $11.00 <br /> Empty'Oil Container UR S 5 5 gal $11.0Q <br /> Empty'Drum wl oil residue NR 5 1 55 gal $11.00 <br /> .f <br /> Processing Fee $20A0 <br /> Method ofPynt: Cash Check# Inv. Total Paid- <br /> , <br /> $146..75 <br /> Stericycle�--heck-ln Attendants Initials! Date: <br /> T N <br />