Laserfiche WebLink
11855 White Rock Rd. <br /> Cl <br /> eanEafth . Rancho Cordova,CA 95742 Date: 8/3/2022 <br /> (916)351-0980 <br /> Time: 8:30 AM <br /> CONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR WASTE CHECK-IN AND CERTIFICATION <br /> RECEIPT AND CERTIFICATION STATEMENT _ <br /> To be completed by the generator: i <br /> I certify that the following Information is correct,and 1 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. imeeeb@gmall.com <br /> Company Name: AP Auto Hospital Company Rep: Imelda Bobadilla <br /> Company Address: 3011 S. EI Dorado Street EPA ID# CAL000425844 <br /> Stockton, CA 95206 Signature: lu <br /> Phone Number: 209-687-6255 Title: *&,(LI14(- <br /> C., Date: <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 WI/ft) (pounds) Meth Cost <br /> Transmission Oil Filters NR _ S 1 5 gal 30 lbs $42.00 <br /> Oil Filters NR S 1 5 gal 20 lbs N/C <br /> Soil/Oil NR S 1 5 gal 30 lbs $42.00 <br /> Processing Fee $20.00 <br /> Method of Pymnt: Cash Check# Inv Total Paid: $104.00 <br /> Clean Earth Check-In Attendants Initials: Date: 3 <br />