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f <br /> G <br /> X1855 White Rotk Rd. <br /> leapEarthRancho Cordova, CA 95742 Date , 10/20/Z021 <br /> ! (916) 351.0980 <br /> Time : 8100 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 1 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 beim 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, ranmal21129outlook.com <br /> Company Name , International Car Care Company Rep : Keith Young <br /> Company Address : 552 E. Lockeford Street EPA ID ff CAL 0189370 <br /> Lodi, CA 95240 Signature : <br /> Phone Number , 209-3650570 Title : ate : <br /> TO BE COMPLETED BY STERICYCLE CHECK-IN ATTENDANT <br /> General waste Description (Chemical Haz. AH State N of Container Total waste Total Waste Disp <br /> Constituent, Ph, WTC.) Class Meta Code SQL Cont. Type/si:e (all / ft) (pounds) Meth COSI <br /> Paper Oil Filters IVR S 6 5 gal 24 lbs N/C <br /> pm F <br /> Processing Fee $ 20.00 <br /> _Method of Pymnt: Cash Checkf# I Inv Total Paid : $20,00 <br /> Clean Earth Check-In Attendants Initials: �' y �' Date,, <br /> TO 39Cd VO dVO �1aN0I1aNN31NI BTSL0966OZ 0Z : 6T TZ0Z18ZI0T <br />