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c� <br /> 11855 White Rock Rd. <br /> (03"lean Eafth Rancho Cordova,CA 95742 Date: 1/27/2021 <br /> (91.6)951-0980 <br /> Time: 2:15PM <br /> CONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR WASTE CHECK-IN AND CERTIFICATION <br /> RECEIPT AND CERTIFICATION STATEMENT _ <br /> To be completed by the generator: <br /> I certify that the following information is correct,and I 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 Conditionally Exempt Small Quantity Generator as defined by Federal and <br /> California State Regulations,and this quantity of waste does not 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,I agree to complete a hazardous waste manifest and comply with ether <br /> state regulations as appropriate. jimatjoes@att-net <br /> Company Name: Joe's Auto Repair Company Rep: Jim QGtC.� <br /> Company Address: 1919 <br /> S.Stockton Street EPA ID# CAL 000 440 652 <br /> Lodi,CA 95240 Signature: "s ; 1,, <br /> Phone Number: - - 209-369-6439 Title: Pf""Z." Date: ZZZ f <br /> TO BE COMPLETED BY STEIRICYCLE CHECK-IN ATTENDANT <br /> General Waste Description(Chemical Haz. AH State #of Container Total Waste Totat Waste Disp <br /> Constituent,Ph,WTC.) Glass Waste Code SACont. Type/Size (gal/ft) (pounds) Iueth CQSfi <br /> Metal Shavings from©rums/Rotors6.1 S .1 I 591 50 lbs $70.00 <br /> ( <br /> 3 <br /> i <br /> Y <br /> Processing Fee $20.00 <br /> Method of Pymnt: Cash Check#x ,�7 Inv Total Paid: $90.00 <br /> Stericycle Check-In Attendants initials: Date: J <br />