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Com, <br /> 11855 White Rock Rd . <br /> CleanEa <br /> Rancho Cordova, CA 95742 Date :7 / 14/2021 <br /> (916 ) 351-0980 <br /> Time : 8 :45 AM <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 Clean Earth 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 other <br /> state regulations as appropriate. aboveja@gmail . com <br /> Company Name : My Mini Mart Company Rep : Ashish Boveja <br /> Company Address : 1756 N Wilson Way EPA ID # CAL000437815 <br /> Stockton , CA 95205 Signature : �--- y <br /> Phone Number : 408- 2044636 Title : - --` Era e : 044 1 j 2.0 <br /> TO BE COMPLETED BY STERICYCLE CHECK- IN A'TT'ENDANT <br /> General Waste Description (Chemical Haz . AH State # of Container Total Waste Total Waste Disp <br /> Constituent, Ph, WTC. ) Class Waste Code SQL Cont. Type/Size (gal ft) ( pounds) Meth COSI <br /> Oil Filters NR S 4 Boxed Sibs N/C <br /> Processing Fee $ 20 . 00 <br /> Method of Pymnt : Cash Check# Inv Total Paid : $ 20 . 00 <br /> Clean Earth Check- In Attendants Initials : '.. Date : ° y�— <br />