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11855 White Rock Rd. <br /> Rancho Cordova, CA 95742 Date: 2/18/2022 <br /> CleanEafth ._, (916) 351-0980 <br /> Time: 8:00 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 /> Cahfcrnia 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. rlopez@hacsj.org <br /> Company Name: Housing Authority County of San Joaquin Company Rep: Rick Lopez <br /> Company Address: 2575 Grand Canal Boulevard EPA ID# CAC9,03461236 <br /> Stockton, CA 95207 Signature: <br /> Phone Number: 209-649-3804 Title: a"e y, D te: —,�.�' w <br /> �U <br /> TO BE COMPLETED BY STERICYCLE CHECK-IN ATTENDANT <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 /> Fluorescent Tubes, 4' UW S 72 each 288 Ift $43.20 <br /> Fluorescent Ballast, Non-PCB NR S 27 each 13.5 lbs $10.80 <br /> Motor Oil NR L 2 5 gal 10 gal N/C <br /> Motor Oil NR L 8 1 gal 8 gal N/C <br /> Spray Paint Cans 2.1 S 72 10 oz 46.94 lbs $65.72 <br /> Zep Mildew Remover and Cleaners 8B L 20 0.95 L 5.02 gal $41.42 <br /> Processing Fee $20.00 <br /> Method of Pymnt: Cash Check# Inv Total Paid: $181.14 <br /> Clean Earth Check-in Attendants Initials: Date: <br />