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0"s t 1855 WHIM ROCKRO F ECEIVED Date ort ,,ent p <br /> a0 SfeCILy'E�i� [tiAN£;€UO COR[>O VA,CA s75742 Tien,. <br /> (966)35t-0990 NOV 0 9 2017 Wormed <br /> Tunes participated <br /> CONDITIONALLY E VAVTITY GENERATOR WASTE <br /> C- ICK-IN RECETPIC A I ICATIO STATEMENT <br /> NT <br /> TO SE,C'OtMPL:ETED D'YGEd g2A'IOP,: <br /> I certify that the following information is correct, and I have read kid understand the requirements for participation in the <br /> Stericycte Conditionally Exempt Small Quantity Generator Waste Acceptance Program. I further certify that I am a Conditioaally Exempt <br /> - -- -Small Quantity-Generator as defused by Federal and California State regulations,and this quantity of waste does hof exceed the specified <br /> limits for the type of waste being disposed: ff this waste is later formd to exceed smalt quantity Crmits or coutaia matadafs not accepted <br /> under this program,I agree to complete a hazardous waste manifest and comply with other state regulations as appropriate. <br /> COMPANY NAME: ee At 1 .e, COMPANY REP: rJe w chfadd <br /> COMPAVYADDRESS: rJ . r� <br /> -'r1'Y,STATE,ZIP: F � SIGNATURE: <br /> �016'EPA.3dYPI3L�NE: � r . <br /> .• _ TITLE ; -DATE: <br /> TO BE'Ce L.ETITE+-D BY'STE CYCIrECHE� INATTE',ND&IT <br /> GENERAL WASTE DESCRIPTION. HAZARD AH STATE S/ P OF CONTAINERWASTE WT(LB) DISP: COST <br /> -=t'IF.[vIIC,4LCONs CiTUEWr 14L.Lr CLAISS WASTE CODE L CONT TYPESIZE - AMOUNT METH. <br /> ,tom <br /> ETHOD OFPAxrAMNT: CASH 13 CHECK 0 CHECK NO. TvTALPAID �✓ " <br /> MRICYCLECHECK-IN A=NDAN'i'S'rtlmu6 S 45 DATE <br /> 207 REvo4n5 CHECK-IN RECEIPT <br /> f <br />