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11855 WHITE ROCK ROAD Date of Event: <br /> �01,0* Stericycle' RANCHO CORDOVA,CA 95742 Time: <br /> • (916)351-0980 Informed: <br /> Times Participated: <br /> CONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR WASTE <br /> CHECK-IN RECEIPT AND CERTIFICATION STATEMENT <br /> TO BE COMPLETED BY GENERATOR: <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. If this waste is later found to exceed small quantity limits or contain materials not accepted <br /> under this program,I agree to complete a hazardous waste manifest and comply with other state regulations as appropriate. <br /> COMPANY NAME: COMPANY REP: 014 Bah Jr' <br /> COMPANYADDRESS: PAID#: t <br /> CITY,STATE,ZIP: ' , SIGNATURE: <br /> COMPANY PHONE: `7�� <br /> (� (IJ 10 �L TITLE: DATE: <br /> TO BE COMPLETED BY STERICYCLE CHECK-IN ATTENDANT <br /> GENERAL WASTE DESCRIPTION HAZARD AH STATE Sl #OF CONTAINER WASTE WT(LB) DISP. COST <br /> CHEKCALCONSZTTUENr Pb. ETC. CLASS WASTE CODE L CONT TYPESIZE AMOUNTMETH <br /> "VY010 oa <br /> 35 m <br /> PIC, <br /> fill <br /> METHOD OF PAYMENT: CASH ❑ CHECK J;( CHECK NO. TOTAL PAIDS ° <br /> STERICYCLE CHECK-IN ATTENDANTS INITIALS DATE <br /> esc-207 REV Dans y-2 CHECK-IN RECEIPT <br /> 5 <br />