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RECEIVEb <br /> 0*0 11855 WHITE ROCK ROAD A}JR 12 2017 Date of Event: �{4t 1 <br /> 0*0 Stericycle' RANCH CORI.YOVA,(.'A 95742 I! (?inYe; <br /> V"59 <br /> (916)351-0980 tNVIRONMEN•TAL H Informed`. _� <br /> HEALTH Times Participated: <br /> PERMIT/SERVICES <br /> CONDITIO ALLY EXEMPT SMALL QUANTITY GENERATOR WASTE <br /> CHE K-IN RECEIPT AND CERTIFICATION STATEMENT <br /> ^� TO.BE COMPLETED BY GENERATOR: <br /> I certify that the followin information is correct,and I have read and understand the requirements for participation in the <br /> Stericycle Conditionally Exempt S all Quantity Generator Waste Acceptance Program. I further certify that I am a Conditionally Exempt <br /> Small Quantity Generator as defm 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 ibis waste is later fowid 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: I' [ �'£ "( I .s. COMPANY REP: G� )5 0"aa.1�� <br /> COMPANY ADDRESS: 61( <br /> .:j r' ( i { r^� EPA ID#: <br /> f_ <br /> CITY,STATE,ZIP: �. ( ( E t.,�+ � SIGNATURE. � _e <br /> COMPANY PRONE: TITLEi _ DATE: <br /> T(I BEMPLETED BY STERICYCLE CHECK-IN ATTENDANT <br /> G&NE SAL WASTE DESCRLPTION HAZARD AN STATE S/ #OF CONTAINER WASTE WT(LH) DISR COST <br /> CH MICAL CONSTITUENT Ph. ETC. CLASS _WASTE: CODR L CONT TYPE/SI AMOUNT METH <br /> METHOD OF PAYMENT: C kSH ❑ CHECK 0� CHECK NO._ _ - TOTAL PAID$ <br /> STERICYCLE CHECK-IN ATTEN ANTS ITIA.S DATE _ tL Lz ( 7^ <br /> i. <br /> PSC-207 KEvansCHECK-IN RECEIPT <br /> 1�1pzs <br /> CHEM CARD ENDING IN <br />