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F <br /> • 11855 WHITE ROCK ROAD Date of Event: October 26,2016 <br /> e*19 Stericyele' RANCHO CORDOVA,CA 95742 Time: 9:0Q am <br /> • (916)351.0980 Informed: <br /> fines Participated: t <br /> CONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR WASTE <br /> CHECK-IN RECEIPT AND CERTIFICATION STATEMENT <br /> TO BE COMPLETED BY GENERATOR: t <br /> I certify that the following information is correct,and 1 have read and understand the requirements for participation in the <br /> Stericyele Conditionally Exempt Small Quantity Generator Waste Acceptance Program. I further certify that I am a Conditionally Exempt <br /> Small Quantity Generator as defined by Federal and California State regulations,and this quantity of waste does not exceed the specified <br /> limits for the type of waste being disposed. If tris waste is later found to exceed small quantity limits or contain materials not accepted <br /> under this program,I agree to complete a hazardous waste manifest and comply with other state regulations as appropriate. <br /> COMPANYNAME: City of Lathrop COMPANY REP: Chris Hart <br /> COMPANY ADDRESS, 21_12 Louise AvenueEPA ID#, CAL 000379085 <br /> CITY,STATE,ZIP: Lathrop CA 95330 — SIGNATURE: G/� <br /> COMPANY PHONE: (209) 941-7465 TITLE: U — __ DATE: �d L20/6 <br /> TO BE COMPLETED BY STERICYCLE CIiECK-IN ATTENDANT <br /> GENERAL\VASTE DESCRUITiON HAZARD Ali STATE S1 #OF CONTAINER WASTE WT(LB) DISP. COST <br /> (CI1EWCALCONSTITUJ NT.Ph..FTC.) CLACS 1VASTE CODE L CONT TYMSI7M, AMOUNT MFTH <br /> Mercury Bromide Test Strip 6.1 1 bag _ _ 8oz <br /> Processing Fee - -- --- ---- - - — — -- -- — --- 2C. <br /> METHOD OFPAYMENT: CASH CHECK ❑ CHECK NO. _ TOTAL PAID$_ 20.6/5 <br /> ST>JRIC'YC1.}:C H 1•'Cl:_}TI A17L'•NUAN"1'5 TNIT'IAI.S �`�. '_ -- DATE <br /> --(� <br /> REV04115 O CHECK-1N RECEIPT <br />