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6! H-955'��MTE ROCK.R.OAD Daieo1'Evcnt: ���' <br /> o� Stet-icycle' RANCHO CORDOVA,CA 95742 Ferntie: <br /> (916)351-0980 ftttoect�ed: da <br /> 'Cuactes i'actici�dC�ci': - �.. __ <br /> CONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR WASTE <br /> CHECK-IN RECEIPT AND CE.RTI CATION STATEME,NT <br /> W BE COMPLETED B'Y,GENET ATOR: <br /> 1 certify that the following information is correct,and 1 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 t'units or eonuin materials not accepted <br /> under this program,I agree to complete a hazardous waste manifest and comIply with other state regulations as appropriate. <br /> COMPANY NAM z ► ,°j" � , •; COMPANY:R' P: <br /> 17 <br /> COMPANY ADDRESS: EPA ID#: <br /> CITY,STATE,ZIP: i~" SIGNATURE: <br /> COMPANY-PHONE: w " TITLE: DATE: <br /> • <br /> TO DE COWL 'ED B"Y'.STE WYCLE CHECK-IN ATTENDANT <br /> fiENERl1LWM M DESCItnMON HA7�!>;Rta /�Ft Zvi. Uf a.° ^ "' <br /> MIRAICA2,. E#.. CWS WASTE CODE L CONT TYPF/S AMOUM' METH <br /> I � t <br /> IEE�'t~i{�1�dIF PKYMN'I: CASH CRECK El CIM-M NO. TOTAI.PAID$ <br /> ./ <br /> IEWCYGLE Ci-IN;Al'Y'IUNDAN'M D4TIALS DATE <br /> C-207 REV0015 CHECK-IN RECEIPT <br /> i <br />