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�►mw4 !I'll WHFTF ROCK ROAD <br /> SfE.`I"icyc[Q' tirktvf IfiO COti�OVR, A 9.5742 Date ar vent: <br /> (9t6)35l-4980 Tirne k i�- <br /> _ . <br /> Times Participated: <br /> CONDITIONALLY EXEMPT SMALL QUANTITY'GENERATOR WASTE <br /> C�Ck=Ilii CEIPTA.ND CEItTMCATION STATEMENT <br /> m. <br /> To BE COMPLETED By iGENE RATOR: <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 Fedzmi and California Stateregulations,and this quantity of waste sloes not exceed the specified <br /> limits foP the type of waste 'being disposed- If this waste is later found to exceed sma[t quantity limits or contain, materials not accepted <br /> under this program,I agree to complete a hazardous waste mataifest and comply with other state regabations as appropriate. <br /> COMPANY NAME: MVI �C,- �6, V( COMPANY REP: KPba k3G� t� e <br /> COMPANY ADDRESS: EPA IDN: '� <br /> 000 <br /> CdTY,NATE,ZIP: d SIGNATURE: <br /> COMPANY PRONE: <br /> TITLE: (� m l4�'1�9"y DATE: <br /> TO BE CONTLET By,STEP-IC'YCLE CHECK-EI ATT NDANT <br /> GENERAf WASTE DESCRIPTION HAZARD AH STATE S/ #OF FONTADMR 7ASTE 7T(L13) DISP.' COST <br /> CiI~tvIICALCO21S3I°Ct1ENT Ph. M. CLASS WASTE COD_ E L CONT TYPMME AMOUNT METH <br /> t�� <br /> �05 <br /> fETH0.D F'P' .'—E 17—. CASI4 "` CHECK 0 CCK Nom- TOTAL PAID, o — <br /> IERICYCLF-C.HpCW-IN ATMNDANTS WR IAL<i <br /> DATE <br /> 0-207 [t VN/1s CIECK-IN RECEIPT <br />