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Stericycle' <br /> 111855 White Reck Rd. <br /> ! Rancho Cordova, CA 95742 Date: 4/10/2019 <br /> {916)351-0990 <br /> Time: 8.30 M <br /> CONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR WASTE CFIIECK-IN AND CERTIFICATION <br /> RECEIPT AND CERTIFICATION STATEMENT <br /> To be, completed by the crimna tor: <br /> I certldy that the fallowing Informafipn is correct,and IF have read and umierstand the fequ irernents for Participation In the Steric le Cond tkwall <br /> Small Quantlty Generator Waste Ac6tptanr*Prograan l fuether certify that i ons a Candnimmtly Exempt Small alua Y erarEilean <br /> California State Regulations,and this gwritityof waste does nvt exceed rhe specifred limits fpr the Cl+ieraFor as deiinrd by Frde,at and <br /> to exceed smalr quantity limits or contacn materials not ac type of waste being disposed.if this w rste is LA found <br /> ceiptrd under this erogram I agrlcta samp4te a hazardaps waste manifest and comply with <br /> orherstate regulations as appro,priat+e. <br /> Company Narne; Domingo Auto Repair Company Re <br /> P Y R: f}prnfngv Cardoso <br /> Company Address: 545 Eden St. EPA lh0#_ CAL 000�V41 182 - <br /> Lodi,CA 95240, Signature <br /> Phone Number; 209-200-0629 <br /> Title: Date: <br /> TO BE C[)MPLETE$BY STERICYCLE CHECK-IN ATTENDANT <br /> Csenerar Waste Description{Chemical Ham. AM State p at container ratal'waste Total Waste <br /> Constituent,Ph,,1ITC_f rya <br /> Class MYrite Code Cant TYPOSire IPI ltt Cost <br /> f Poun�hl +ateen <br /> Oil(Non Contaminated) 9 S 1 -30 gal 30 — <br /> 011 Filters50.00 <br /> 9 S 1 5 gat _ 0,00 <br /> Absorbent g 5 1 S gal 25 <br /> Metal 5havfngs 9 $35.0(} <br /> — 5 1 1 lb <br /> $1.40 <br /> Processing Fee <br /> Method of PVmnt: Inti Total Paid-cash hetkM $2040Sterlcyrcle Check-In Attendants Initials; <br /> Date: $56.40 <br />