Laserfiche WebLink
S t e r i c y c/i 11115 WHITE ROCK ROAD DaLe of Event: <br /> RANCI40 CORDOVA,CA 95742 Time: <br /> (916)351-09&0 <br /> fnfemied: <br /> Tiluts PWtiCiDaWd: <br /> CONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR WASTE <br /> CHECK-IN RECEIPT AND CERTIFICAT14DN STATEMENT <br /> TO BE, COMPLETED BY GENERATOR: <br /> I certify that ti)ue following information is correct,and T have read'and understand the requirements for parti.cipatiou. in the <br /> Stericycte Conditionally Exempt Small Quantity Generator Waste Acceptance Program. 1 further certify that I am a Conditio'aaliy Exempt <br /> Small Quautity Generator as defined by FeAeraf and California State regulations,and this quantity of waste does not exceed th6 speci.tied <br /> limits for the type of waste being disposed. if this waste is Later found to exceed small.quan t'tY limits or coalain materials <br /> 'In not accepted <br /> der this program., I Wee to complete a hazardous waste manifest and comply with other state regulations as appropriate. <br /> COMPANYNAME: <br /> 1CONIPANY RE,?: <br /> COMPANYADDRESS: <br /> CITY,STATE,ZIP: <br /> SIGNATURE- <br /> COMPANY PHONE-- <br /> (210 *2 Tf LE � DAT E- <br /> -—------------ <br /> TO BE COMPLETED BY STERICYCLE CHECK-IN ATTENDANT <br /> GENERAL WASTE DESC <br /> AR <br /> CWSTITUR WAST S C TS I #OF Co DiSR COST <br /> TL CONT TYPE/SIZME <br /> 14 <br /> LA_eTp 4 Eok- <br /> YU <br /> �j <br /> WETHOD OF PAYMENT.- CASH CHECK Q C,145CK NO. TOTAL PAID <br /> ;TERICYCLE CHECK-IN ATTENDANTS INITIALSDATE _._--_7_-Rfl-7 <br /> SC-207 REV 04115 <br /> CITECK-DIN RECEIPT <br />