Laserfiche WebLink
.pp <br /> ]1185 WHITE ROCK ROAD Date of Event: May 4 2£116 <br /> 0 StericyCl1e• CHO CORDOVA,CA 95742 Time: — R <br /> . 8:S0am <br /> • (91(1)351-0980 Informed: <br /> Times Participated: + <br /> �. CONDI TONALLY EXEMPT SMALL QUANTITY GENERATOR WASTE <br /> BECK-IN RECEIPT AND CERTIFICATION STATEMENT <br /> TO BE COMPLETED BY GENERATOR: <br /> I certify that the foll whig information is correct,and I have read and understand the requirements for participation in the <br /> Stericycle Conditionally Exempt pt 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 this 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: NorC berg ECO Solutions, Inc, COMPANY REP: Eric Nordbefg <br /> COMPANYADDRESS: 3 El Qorgdg St. EPA ID*- CAL 000373387 <br /> CITY,STATE,ZIP: Stoc ton CA 85206 _ SIGNATURE: <br /> COMPANY PHONE: E209) 64 -1134 TITLE: DATE; <br /> TO BE COMPLETED BY STERICYCLE CHECK-IN ATTENDANT <br /> QL MU L WASTE DESCRIPTi HAZARD AH STATE S/ #OF CONTAINER WASTE WT(LB) DISP. COST <br /> CIIHMICALCONSTITUENI' Ph.,HTC,1 CLASS WASTE CODE L CONT TYPRJSIZE AMOUNT METH <br /> Diesel Soot/ Air Filter 9 18.6 24.18 <br /> iesel Soot/ Latex Gloves g 44.8 58.3 <br /> Scratch Pads 95,44 24.07 <br /> n <br /> Processing Fee 20- <br /> METHOD OF PAYMENT: CASH Cl CHECK CH K NOTOTAL PAID$ 226.52 <br /> STF,RICYCI,E CHECK-IN ATT ENDANTS INITIALS J DATE <br /> -�� <br /> Nac•za� aev nv�a CHECK-1N RECEIPT <br />