Laserfiche WebLink
EEl1.1 E D <br /> i• 1 t 855 WI4YfE ROCK ROAD wh" <br /> J <br /> !�N Irate of Event: <br /> #� Sterr'c�pcle RANCHO CORDOVA,CA 95742 �J1 $ 2 0 i 8 �- <br /> ��� (916)351-0980 Time: <br /> Informed: <br /> EN i,ROUk',Ez,i,,a,! Times Participated: <br /> CONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR WASTE <br /> RE COWLETED BY GEP TOR. <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 wasft beim dash If jbiwaste is laW fowd to exceed y Nmfts w er,% M L rAs aot ated. <br /> under this pro a,Ti agree tO Complete a hawdous via Maw Md,comply with other staft regujt4fiow as ap ciprit.e_ <br /> COMPANY NAME: /: ry, a V"a" COMPANY REP: <br /> u➢MPANYADDRESS: ' � , PA ID : <br /> CITY,STATE,ZIP: �r � C4 SIGNATURE: <br /> CA z ) g - 4r, -IT - � r DAR <br /> TO RE COA LFT) BY=PacycLig C J� �i �'DIP� <br /> GENERAL WASTE DBSCRIPTIQN HAZARD AH STATE S/ #OF CONTAINER WASTE WT(LB) DISP. COST <br /> CHEMICAL CONSTITUENT Ph. BTC. CLASS WASTE CODE L CONT TYPESIZE AMOUNT. MBiTFI <br /> I Sg �� <br /> b <br /> 4 if <br /> t <br /> n, <br /> MOD, CAS Q, ` >i:' � "� � <br /> 'r"d' C2. i vim. . 1_0!rAl;PAVD S r y <br /> _UCYCLE 4ECK=IN AT`I_ND3ANj-M N IAI.S BATE _2 �--f— <br /> PSC-207 UV 04/15 <br /> CHECK-1N RECEIPT <br />