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6"® 11855 %V141 Ff- ROCK ROAD <br /> 10 013 Stericycle' RA N.0 fj<)C <br /> 0.0 ORDOVA,CA 95742 Ticnt <br /> (916)351-0990 <br /> lfomied: <br /> Times Participated: <br /> CONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR WASTE <br /> CHECK-IN RECEIPT AND CERTIFWATION STATEMENT <br /> TO BE COMPLEWD BY GENERATOR: <br /> I certify that the following information is correct,and I have read and understand the requirements for participatioa in the <br /> Stericyc[e Conditionally Exempt Small Quantity Generator Waste Acceptance Program. I further certify that I am a Conditio'aally 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 later found to exceed swall quantity Limits or contain,materials not accepted <br /> ander this program, I agree to complete a hazardous waste manifest and comply with other state regulations as appropriate. <br /> ::OMPANY NAME: a I YILCOMPANY REP: <br /> ::OMPANYADDRESS: EPA ID9: 0 <br /> �fTV,STATE,ZIP: SIGNATURE- <br /> `OIMPANY PHONE: T'IT'LE: .6 Vvi DATE- V-) <br /> TO-13E COWLETRIDBY ST.RRICYCLE iCHF_C.K_jN ATTF."A.NT <br /> GtRERkL WASTE DESCkHMON HAZARD AH STATE S1 #OF <br /> :1 WWCA L QNM.V01W.Ph-ETC.) CLASS WASTE CONTAINER WASTE DISP.- COST <br /> CODE L CONT TYPES= —AMOUNT Nim <br /> e. <br /> COA lvf� <br /> cmk <br /> YO <br /> ETHOD OF PA"JEN-r. CASH 0 CHECK CHECK <br /> No. l OTAL 10A S. (51 q 4 <br /> -EPICYCLE CHECK-W,A—FrENDANNIS U4TMkU. DKf E <br /> CHECK4N RECEIPT <br />