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11855 WH f J'f' k0C1;. R 0 A 1) D ate 0 r f;vcra <br /> 0 Stericycfe' RA NCH0 COR DIDXIA,C.A 2 <br /> (9'16)354-09,80L f rtrormed: <br /> CONDITIONALLY EXJ61\4PT SMALL QUANTITY GENERATOR WASTE <br /> CHECK-IN REC EIPT ANI) CERTIFICATkON STATEMENT <br /> TO BE, COMPLETED BY,,GENLA R .TOR: <br /> I certify that the following information is correct,acid I have read•and understand the requirements for participation in the <br /> .icycle Conditionally Exempt Small Quantity Generator Waste Acceptance Program. I further certify that[am aConditio'nally Exerapt <br /> it(Quantity Generator as defined by Federal and California State regulations,and this quantity of waste does not exceed the specified <br /> its for the type of waste be*disposed- If this waste is Later fond,to exceed sroaff qtizatity limits or contaia mafmials not accepted <br /> er this:program,I agme to emplete a hazardous waste manifest and,comply with other state reguladow as appropriate. <br /> CO M PAN Y RE,F: <br /> %IPANY NAM: 5-MVRC-� <br /> KPANYADDRESS: 11.613 <br /> q01 EPA[Dg: Ut...- <br /> Y,STATE,Mr: SIGNATURE: <br /> APANY PHONE: TrME: DATE. <br /> TO BE C<)NTLETED BY STERJCYCLE CRECK-LI;ATTENDANT <br /> Fq�fC WATM-bESCPIPnM ,YCD AR STALE SY 9 OP CONtkWM -WAM Wr(03) DVSV. :I 05ST <br /> WCALCONSTnU WASTE CODE L CONT TYPFBME AMOUNT <br /> ,ENT CLASS <br /> ,Ph.,ETC) ivtEITi <br /> v wquy- L-7) <br /> -VSKAv-- nt <br /> J,4 � JW5 <br /> "q <br /> HOD 01PAYMkNT-. CASH CIMCK 0 [ECK Nb TOTAL PAID s 2,q <br /> :ICYCLr--CI-LE-CK-INATTr-.MAN-,-iS:WrffA�.S 147 D— <br /> KEV 04115 <br />