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f <br /> 4ef• 11855 WHITE ROCK ROAD Date of Event: _OCtObt f 26,2016 <br /> *� Stericycle RANCHO CORDOVA,CA 95742 Time: 9;00 am <br /> go* <br /> (9)6)351.0980 Informed: <br /> Times Participated: t <br /> CONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR WASTE <br /> CHECK-IN RECEIPT AND CERTIFICATION STATEMENT <br /> f <br /> TO BE COMPLETED BY GENERATOR: <br /> I certify that the following information is correct,and 1 have read and understated the requirements for participation in the <br /> Stericycle Conditionally Exempt Small Quantity Generator Waste Acceptance Program, I further certify that I atn 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 rhis 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 /> COMPANY NAME: City of Lathrop COMPANY REP: Chris Hart <br /> COMPANYADDRESS: 2112 Louise Avenue EPAID#: CAL 000379085 <br /> CITY,STATE,ZIP: Lathrop, CA 95330 SIGNATURE: G/, <br /> COMPANY PHONE: (209) 941-7465 TITLE: U� DATE: d 20 <br /> TO BE COMPLETED BY STERICYCLE CIIECK-IN ATTENDANT <br /> GENERAL WASTE DESCRIPTION HAZARD AH STATE Sl #OF CONTAINER WASTE WT(LB) DISP. COST <br /> tCIIENECALCON STITIJF.NT.Ph..ETC.e CJ.ASS WASTE CODE L CONT TYPPIsizF. AMOUNT NIFTH <br /> Mercury Bromide Test StqLs 6.1 — 1 ba q _— 80Z <br /> Processin Fee -- --- --_- _ . ----- — ----- ---- — l <br /> � _ 20- <br /> METHOD OF PAYMENT: CASH A CHECK EI CHECK NO,__ _ TOTAL PAID$ 20.65 <br /> STERICYCLE CHECK-1NATI'ENDANTS INITIALS ' �. -- -. _ DATE <br /> Psc-:a. 10�v04,0 O CHECK-IN RECEIPT <br />