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o� 11855 WffTE ROCK ROAD <br /> 00 Stec icycle' RANCHO CORDOVA,CA 95747_ Daae of'Event "( <br /> (91t6)35 f-0980 Time, <br /> f i�tfo��d: <br /> CONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR WASTE <br /> CHECK-IN RF—CEI,PT AND,CERT:IRCATION STATEMENT <br /> _._ T`O .'BE C-OMPLETED JBY GENERAT<)R: <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. 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. IE this waste is later mud to exceed small quantity 4'uaits or cow cm materials not,accepted <br /> under this program.,I agree to,complete a hazardous waste manifest and comply with outer stag regulations as appropriate. <br /> COMPANY NAME. COMPANY REQ: Kettlo,w ` <br /> COKPANY ADDRESS: <br /> EPAIDf: <br /> CITY,STATE,ZIP: SIGNATURE: CL <br /> C,OMF'i<tN'Y PATE: lu <br /> TITLE: ()e1A11CA <br /> d:I' tvnt <br /> -DATE- <br /> TO <br /> BATE; <br /> TO 13E COWLETED JB_V ST&R11CYCL �CEU C-IN ATMNDANT <br /> GMgULp;; LyvM DPSI rTIOYHAZARD I � !TE <br /> _4__jWATCAL CLASS CODE CONT � <br /> Ut�u�l'^- M—4 <br /> d <br /> A " NI <br /> I 5 <br /> MTHOD OF P:j YMafr: CASITI Cy CHECK 'Q C K No. TOTAL PAW$ <br /> IEWCYCLECHECK-IN ATTE1,MAN7M INII'.ALS _w DATE <br /> c-�o7 ttEvoans CHECK-IN"C"EIPT <br /> r <br />