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Rac <br /> CleanEadacho dov , CA 95 . <br /> kancha Cordo�+a, CA 95742 p3tG; 3125J2026 <br /> (9161351-0980 <br /> Time: 9.30 AM <br /> CONDITiONALL`! EXEMPT SMALL QUANTITY GENERATOR WASTE CHECK-IN AND CERTIFICATION <br /> RECEfPT AND CERTIFICATION STATEMENT <br /> To be completed by the generator: <br /> I reirtify that the Fpllowhig inforrnatFon is correct,mild I have read and u nderstend the requl rements kw pa rumpatipn 4n the Clean Earkfti Conditlanaily <br /> Exempt Small Quantity Generator Waste Acceptance Program_i further Certify that I am a Conditionally Exempt Small Quantity Generator as defined by <br /> i:eders I and California State Regulations,and this qua rctltw of waste does not exceed the spesifled limits for t h a type of waste Icing disused,if this waste <br /> is I ater tDund to emceed sma 11 qu antlty 11 rr►Its or contain materials not bwepted u ncl Er this grogra m I agree to romplete a hazardous waste m Dnifest a nil <br /> c4rnpN with other state regulations as appropriate, taylorpWwreral.wm <br /> Company Name: 1-ustre-Cal LLC Company Rep, Taylor Pate <br /> Cornpany Address. 715 5 Guild Ave EPA ID# #7f]fJ4 <br /> Lodl Ca 95240 Signature{ <br /> Phone Number: 209-37G-1617 Title; Date: <br /> To IS COMPLETED BY CLEAN EARTH CHECK-IN AETTENDANT <br /> General Waste Description(GhemicaJ Ha:, AN State #of Container Total waste Total Waste Nsn Conitit Lent,Ph,WTC,I [lass WASM Cade 5fL Cost <br /> Cont. Typejsw! (&a'Iftl [wundo Melh <br /> FIuarescentTubas01 U W S 337 ea/box 1148ft $202.00 <br /> UV Tubes Ot U W S a ea $16,00 <br /> Alkaline Batteries UW 5 1 box 9 Ibs $5.30 <br /> Used Oil NR L 3 5gal NC <br /> Used Oil Filters NR S 1 box NC <br /> Processing Fee [_ <br /> Method of Pymnt; Check# CIC o Af CC �O <br /> Clean Earth Check-In Atten6nts Initials; Y, 5, Date: 31 z- <br />