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Co. <br /> 0 a 11855 WRITEROCK ROAD Gate of Er vent <br /> Ste <br /> r'Cyele' R-ANC>tO COF DOVA,CA 9.5742 CEa?ie — <br /> (9 t6)3 S&-0990 lctFarrsned: <br /> Times Participated: _ <br /> CONDITIONALLY EXEMPT SMALL.QUANTITY GENERATOR WASTE <br /> +C C!{-zlN RECEIPT AND CERTfFfCATION 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 Getierator as defined by Federal and California State regulations,and this quantity of waste does not exceed the specified <br /> Limits for Fixe type of waste being disposed If this waste is later found to exceed smalt quantity limits or contain materials not accepted <br /> under this presgram,I agree to complete a hazardous waste manifest and cotttply with other state regulations as,appropriate. <br /> COMPANY NAME: MAVI 1 l� e 5A 4COMPAiYY ItEY: 1�' <br /> COMPANYADDRESS: '2,, .� EPA IM: jM <br /> CITY,STAlT,ZIP: TyjSIGNATURE: <br /> COMPANY PHONE: (�Q TITLE: CI `�/y��gn c�� DATE: <T_3o <br /> TO BE COMPLETED BY,`STERICYCLE CHECK-1N ATTENDANT P <br /> GENERAL WASTE DESCRIPTION HAZARD AK STATE Si #OF CONTAMER WASTE WT(LB) DISP' COST <br /> CIfe. ICAI,CONSITrUWT ph. ETC. CLASS WAST& CODE L CANT TYPE/S1ZFs __AMOUNT METH <br /> 1')2 Cit 5 . <br /> W&TROD 0*PAYAUNM CASH.AK IMMLCx 0CHECK NO. TOTAa.Pie <br /> DATE _ <br /> G207 CHECK-IN RECEIPT <br />