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12 / 07 / 2021 14 : 06 2097270803 JOHN PAGE 04 <br /> 11895 White Rack tido <br /> Rancho Cordova# CA 85742 Date . <br /> 80 <br /> �9AB} 851 <br /> 111m s. FM <br /> CONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR WASTE CHEMIN AND CER11FICATION <br /> RE+ EiPT AND CER" KATION STATEMENT ENV <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 Pro !gam. I further certify that I am a conditionally Exempt small Quantity Generator as defined by radsrai and <br /> califomia state Regulations, and this quantity of waste does not exceed the spoified limits for the type of waste being disposed. if this waste is later found <br /> to exceed small quantity Umtts or contain materials not accepted under this program I agree to complete a hatardous waste manifest and comply with other <br /> state regulations as appropriate, knookS10hotmell.com <br /> Co►npRny Name: OWPAC, inc. dba torkehwd Auto Repair Company Rep : Marla Kendrick <br /> ompa ny Aticlres t x1962 f!lv9s0M Court EPA IIF D # L ' <br /> I c�wchfOrdt CA 95257 Signature: <br /> IF Phonic Numbo III I4 21Nµ227=0900 Title � „ � f'"��cl�;: .. .. � l � .. . . . <br /> TO BE COMPUTED BY STERICYCLE C"ECK»!N ATTENDANT <br /> ••. st <br /> General waste Description (Chemical Haz. AH State q of cantsNesr Ttrtai waste Total Waste ' Cost <br /> Constltuam Ph, WTC j Class Waste Dade cont. Typtfsho (01 / 110 (pounds) toted+ • <br /> Metall u# 41 n 10 8. . S 5 gal 60lbs . . . .bLA IF 11 1 1$84:40 <br /> P�lnt G. 1 6 i~ 6 1 # ai t I $ 9R5Q <br /> L IF <br /> IF IF <br /> Vow M-PW <br /> FIII <br /> Pretessin FePool <br /> $20.00 <br /> + . . . . .: <br /> Method at Pymnt: rash checkInv Total Paid: <br /> - W Date; ..� <br /> ! at Clean earth Cheek-lit Attendants itlitiais: <br />