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46• 11855 WHITE ROCK ROAD Date of Event st _ <br /> ,0 Stericycle' RANCHO CORDOVA,CA 95742 Time, `' /.`>r Yes t, <br /> (916)351-0980 Inm <br /> fored: <br /> Times Participated: <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 /> 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 limits or contain materials not accepted <br /> under this program,I agree to complete a hazardous waste manifest and comply with other state regulationsas appropriate. <br /> COMPANY NAME: ( ff'ltiI7IL /L) COMPANYREP: <br /> COMPANYADDRESS: N76V E &'j EPA IDN: 0144Q�(j:,�(��/ '!�1 <br /> CCR;STATE,ZIP: L.Jr)d E.'!7 C,lj I�::�'c3(p SIGNATURE: / <br /> COMPANY PHONE: "(0) Jl'rtY'•e/� TITLE: JAG1/4r DATE: <br /> TO BE COMPLETED BY STERICYCLE CHECK-IN ATTENDANT <br /> GENERAL WAS IT_DESCRIPTTON HAZARD AH STATE S/ XOF CONTAINER WASTE WT(LE) DISP COST <br /> CIMMiCALCONSTITI.TrUl" Ph HTC.) CLASS WASTE CODE L CONT 7"YPE/SCLr. AtNIOUNI "ETH <br /> t- E <br /> EN I r� -- <br /> DE IH- - - -- <br /> METHOD OF PAYMENT: CASH 31 CHECK ❑ CHECK NO._ TOTAL PAID S v <br /> 9 <br /> 3TERICYCLE CHECK-IN ATTENDANTS INITIALS Z• _ DATE __ V / _ <br /> 'SC-207 REv04r0 CHECK-IN RECEIPT <br />