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*1M It 855 Wf4rfE ROCK f20 D Date of Event: ��1..,( <br /> ► 5ter+cycle' RNCI-10 COt IX)VA,CA 95742 <br /> (9 16)35.[-x990 Time: <br /> Informed: <br /> Tunes Participated: _ <br /> CONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR WASTE <br /> CHECK-IN RECEIPT AND CERTIFICATION STATEMENT <br /> TO BE COMPLETED BY GENERATOR: <br /> I certify that the"foitowing uiformation is correct,and I have read and understand the requirements for participation in the <br /> Stericycle Conditionally Exempt Small Quantity Generator Waste Acceptance Program. I further certify that I am a Conditionally Exempt <br /> Small Quantity Generator as defined by Federal and California State regulations,and this quantity of waste does not exceed the specified <br /> limits for the type of waste being disposed. If this waste is late.-found_to cxpped small quantity limits,or contain materials not accepted <br /> under this program,I agree to cowpleta a haaardma waste auknifest and comply with othw state regulatims as appropriate. <br /> COMPANY NAML,—. # r � <br /> COMPANY ADDRESS: � t EPA ID#: j] <br /> CITY,STATE,ZIP: [1 � , <br /> J T SIGNATURE:COMPANY rHoluE: q-) - <br /> -To 13E COMPLETED BY STERICYCLE ATTE1 ANT <br /> GENERAI.WASTE D$SClrIpITQN D STATE St #OF CONTAINER WASTB Iii jI.H), 1aISP COSI <br /> AI.C!l t'1Y1 't l'ii,�'C. SLA S WASTE CODE L CONT TYPEBUE AMOUNT METH <br /> f <br /> . . <br /> L <br /> � l <br /> s <br /> WX, MOD OF PAYS CASE 0 CHECK INO ��r���'� TOTAL PAID s <br /> STERICYCLE CHECK-INATI'ENDANTS INMALS DATE 'J <br /> ,Psc-W? V*.vran5 CHECK-1N RECEIPT <br />