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t 1855 wHrrr Rocs;2anD125( ' <br /> �� Steric rCl2" Date of Evcnt: ' <br /> y (tANCr{O CO[tDOVA,CA 9s 742 - Time: <br /> (916)351-0980 Informed: fr <br /> Tures F-r,ticinated: _ <br /> %CO1DI&d1iAJ$ $ E , uWCSMALL QUANSUZ GENERATOR <br /> WASTE <br /> CHECK-IN BEGETST AND CERTIFICATION STATEMENT <br /> TO BE COMPLETED BY GENERATOR. T <br /> I certify that the following information is correct,and I have read and understand the requirements for participation in,the <br /> Stericycle Conditionally Exempt Small Quantity Generator Waste Acceptance Program. 1 further certify that I am a Conditionally Exempt <br /> Small Quantity ,(generator as defined by Eeder-a.Tand Calif&raia State regulations,and this quantity of waste does not exceed th,specified <br /> limits for the type of waste being disposed.. If this waste is later found to exceed sraali quantity Iimits or contain,materials 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: !��Y ��Q y+ -COMPANY REP: <br /> COMPANY ADDRESS: t EPA ID#• D <br /> aTYC,STATE,zIP. SIGNATURE: <br /> C[;MPAI+IY HONE- — <br /> Ti'I°LE; t')m �,r.�`'�r:/ DA'C'E: <br /> TO BE COMPLETED BY STERICYCLE CHECK-IN ATTENDANT <br /> GENERAL WASTE DESCRMTION FiAZA[LD AH S'EATF. SJ COLrAMEZ W4StL' OI9U C jtVIE1 g{ _C <br /> 7STiECOD3 L CYESdfi AMOUNT <br /> v r <br /> x <br /> r <br /> 57 <br /> ------------------------- <br /> f <br /> S 4 <br /> THOD E)F PAYMENT: CASH CHECK CIC Nt7. TOTAI PAID$ <br /> ;TERFCYCLE CRECK-WATI'ENDANIS INITIALS DATE _...-v..--7_R l-7 <br /> SG207 REV 04115 <br /> CHECK-IN RECEIPT <br />