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11955 White Rock Rd. <br /> FeanEafth Rancho Cordova,CA 95742 Date: 3/18/2022 <br /> (916)351-0980 <br /> Time: 3:OOPM <br /> CONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR WASTE CHECK-IN AND CERTIFICATION <br /> RECEIPT AND CERTIFICATION STATEMENT <br /> To be completed by the generator: <br /> ertify that the following information is correct,and I have read and understand the requirements for participation 1n the Clean Earth Cond itio n a fly Exempt <br /> nall Quantity Generator Waste Acceptance Program.I further certify that f am a Conditionally Exempt Small Quantity Generator as defined by Federal and <br /> alifornia 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 <br /> other state regulations as appropriate. kalerDol@gmail.com <br /> )mpany Name: Delta Arco Company Rep: Raj Singh <br /> 3mpany Address: 440 W Dr. MLK Boulevard EPA ID# CAL000377209 <br /> Stockton, CA 95206 Signature: <br /> lone Number: 209-5942100 Title: ry Date: <br /> TO BE COMPLETED BY STERICYCLE CHECK-IN ATTEN©ANT <br /> 3eneral Waste Description tChemical Haz. AH StateS'L #of Container Total waste Total Waste Disp <br /> Constituent,Ph,WTC.) Class Waste Code Cont. Type/Size (galft) (pounds) Meth Cost <br /> jel Filters, 12 quantity NR S 1 5 gal $1.2.00 <br /> -ocessing Fee <br /> $20.00 <br /> ethod of Pymnt: Cash Check# Inv Total Paid: $32.00 <br /> can Earth Check-In Attendants Initials: � "` Date: P j- <br />