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1 M55 WfIITE F$t"X'K ROAD <br /> Stericycle' RANCI-r0 COtxf3(�V;+1,CA 95742 <br /> Date of Event: <br /> ` (916j 354-09$0 Time: -* J <br /> Informed` J <br /> Tunes,Participated: <br /> CONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR WASTE <br /> CHECK—IN RECEIPT AND CERTIFICATION STATEMENT <br /> TO BE SMP LETED:BY GENERATOR: <br /> I certify that the following iuiformation 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,quantitylimits,or contain materials twt accepted <br /> under this program,I agree to C64WIOtO a hazardnt waste maWfest <br /> and comply with other sty regulations as appropriate. <br /> COMPANY NAMI•;: G�"t, trA g <br /> � * COMPANY REPS 6 <br /> COMPANY AD D KESS: 32— EPA ID#: 1 } .� 2.- -7 <br /> CITY,STATE,ZIP: t SIGNATURE: fi .— <br /> COMPANY PONE: T.ITGE: <br /> DATE: , v`j) - <br /> TO DE COit'XPL RTED BY STER1CYd✓LE C)HjC K-jt�L7°T°]��11��ITT <br /> GMMAL WASTEDESt:ltII7tOAt HY tZD Arr STaE-MMUCAS7 #QF co N€ASTE WC <br /> ` t C frLASS WASTE CODE L CONT TYPESIZE AMOUNT IJIv1E7�'Ii G(7�ST <br /> ell a� 2. q raj <br /> ' cyl <br /> 69. <br /> M"M-01)OF PAY 'CAM C! CHECKC'�fid0. 7 C)I <br /> ' <br /> -STERIC.§fCLE CHECK:-IN ATNIS <br /> BQTI?#LS `l�'T'ALPAW <br /> DATE <br /> fsC-W? <br /> CHECK-(N RECEIPT <br />