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Date of I-vi <br /> 0-0 ID Sterkycfe' F-3 E C F I E" <br /> 00 11855 WF11 IT ROCK ROAF) nit: <br /> ® a RANCK0 CORDO VA,CA 95 74 2 V <br /> (9[6)35 L-0980 �nfomicd: <br /> J"J'N 18 120 13 Times Panicipated: <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 /> Stericyc[e Conditionally Exempt Small Quantity Generator Waste Acceptance Program. f ftalbLer certify that I am a Conditionally FKCMPC <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 riot accepted <br /> ander this program,I agree to complete a hazardous waste manifest and comply with other state regulations as appropriate. <br /> OMPANYNAf4E: <br /> COMPANY REP: <br /> �OMPANYADDRES< EPA[D#: <br /> :ITV,STATE,ZIEP: SIGNATURE: <br /> Iftil <br /> TrrLE: 6 ,"x, DATE- <br /> 'OMPANY PH-ONE: <br /> T0,13F,COMYLETED.WSTERWYCLE CHECK-1N AXTE"ANT <br /> m4tmf WASTE DIMCR"ON HAZARD AH STATE S/ #OF CONTAINER WASTE Vft(LB) DISP. COST <br /> �MgCAL CC*(=r0Wr Pit.,M-Y CLASS WASTE CODS L CONT TYPWSEZF, AMOUNT METH <br /> '.0 7 <br /> _ A <br /> IV <br /> �VULT <br /> Alp& 6 •ST) <br /> U <br /> L <br /> ETHOD OF PAYb=,NT. CASH El CHECK 9t QHECK NO. TOTAL PAJ15�$ <br /> e— a <br /> 16-1 7 <br /> E RIC YCLE cHECK_,Rj ATTENDANTS fiqVTL&AS DKfE <br /> REV04/15 CHECK-IN RECEIPT <br />