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11855 White Rock Rd, <br />.41 Rancho Cordova, CA 95742 Date: 6/23/2021 <br />111 )1) (916)351.0980 <br />Time: 8:116AM <br />I CONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR WASTE CHECK-IN AND CERTIFICATION <br />RECEIPT AND CERTIFICATION STATEMENT <br />I I certify that the following Information is correct, and I have read and understand the requirements for participation in the Clean Firth Conditionally &emPt <br />Small Quantity Generator Waste Acceptance Program. I further candy that l am a Conditionally Exempt Small Quantity Generator as defined M Federal and <br />California State Regulations, and this qua nifty of wane 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 harardous waste manifest and comply with other <br />state regulations asaporopdate. <br />mikeQascock[onpropelkr.com <br />Company Name: Stockton Propeller, Inc. Company Rep: Mike Belmont <br />I <br />1a151 Will.. anad EPA ID # CAL .830 <br />T'nle: St9YVrCi v <br />Meth", of Pymm: rash Check# <br />Clean Earth Check -In Attendants Initials: <br />CagDR CARD ]ENDING 0 <br />TO BE COMPLETED BY STERICYCIE CHECK-IN Af 1 LNUAmI <br />General Waste DescriptIsm (chemical <br />Constituent, Ph. WTC.) <br />Fluorescent Bulbs, 4' <br />Fluorescent Bulbs, 6' <br />Fluorescent Bulbs, 8'_ <br />Fiuorescent Bulbs, 2' <br />Ham. AN <br />Class wane <br />UW <br />UW <br />UW <br />UW <br />State <br />Code <br />S/L <br />5 1 <br />S <br />5 <br />5 <br />Nof <br />Com. <br />187 <br />2 <br />5 <br />2 <br />Container <br />TvW/Sa"? <br />Bulbs <br />Bulbs <br />Bulbs <br />Bulbs <br />Tmalwaste Total Waste <br />igal/ft) (pounds) <br />7481ft <br />121ft <br />401ft <br />4 Ift <br />olsP COSI <br />Neth <br />$112.20 <br />$1.80 <br />$6•� <br />$U.60 <br />Processing Fee <br />o�:dC" <br />$20.00 <br />SS4Q.60 <br />Meth", of Pymm: rash Check# <br />Clean Earth Check -In Attendants Initials: <br />CagDR CARD ]ENDING 0 <br />