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04/07/2016 23:30 2099437Q�3 WILD HORSES 4X4 PAGE 03/04 <br /> M r 11855 WHITE ROCK ROAD Dme of Evaat, egrg 8,2016r <br /> r�o Stieticyeie' RANCHO CORDOVA,CA 95742 Time: B:OOam <br /> ° (916)331.0980 Informed: <br /> Throes Participated: <br /> CONDI'T'IONALLY EXEMPT SMALL QUANTITY GENERATOR WASTE <br /> CHECK-IN RECEIPT AND CERTIFICATION STATEMENT <br /> TO BE COMPLETED BY GENERATOR: <br /> 1 certify that Cho following information is correctand I have read and understand the requirements for participation in the <br /> Stericycie Conditionally Exempt Small Quantity Generator Waste Acceptance Program. I fin ther certify that 1 am a Conditionally Bxempt <br /> Small Quantity Generator as defined by Federal and Califbmla State regulations,and this quantity of waste does not exceed the specified <br /> limits for the typo of waste being disposed If this waft is later found to exceed small quantity limits or contain materials not aeceptod <br /> under this program,I agree to complete a hazardous waste manifest and comply with other state regulations as appropriate. <br /> rOMPANYNAME: Wild Worsen: Inc. COMPANYREP: David Seibold <br /> COMPANYADDRESS: 1045 S. Cherokee Lane rFAma: QAC 002852538 <br /> CM,STATE,zrn: Lodi. CA 95240 SIGNATURE; <br /> COMPANYPHONE: (209) 4¢0-7200 TITLE; DATE.- <br /> TO <br /> ATE:TO BE COMPLETED BY STERICYCLE CHECK-IN ATTENDANT _ <br /> 0ENERAL WASTn)DESCRIPTION HAZARD AH STATE S1 $OF 00MMNER WASTE WT(I.e) DISP. CAST <br /> 2@hff LCAN9 (ln. <br /> TITE%h Y-_Fr 84 ASM CODF I CONT TYIT/S1 R AMQVNTMETH <br /> Metal Fines 4.1 1 ba • 0.48 0.82 i <br /> r . ssin(a Fgg -- <br /> G. <br /> E <br /> METHOD OF PAYMENT: CASH ❑ CHEC.K. Q CHECK NO. S.S 7..7 TO'T'AL PAID$-2DD_M— <br /> STERICYCLE CHECK-IN ATTENDANTS INITIALS�_ 7 DATE L�r' <br /> rscae7 aavrana CHECK4KRECEIPT <br />