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09/0912018 PM 10, 36 HA2 . ,y��q E E • <br /> SEP 14 20%11355 ^-- <br /> su"cyde- kANCHO 0'01 VA,CA 9sra2`kVIROkd(ENTRL HFJVL7}{ k ufnvcm ember 8,2018 <br /> R.� PERMIT/SERVICES �pe' ,&QDpM <br /> (916)351-u9R0 L,Wrmuk <br /> 'l4,a:a pattiuiPatcd: <br /> CONDITIONALLY ZXEMPT SMALL QUANTITY C&NERAIVR WASTE <br /> CRECK-IN RECEIPT AND CERTIFICATTON STATEMENT <br /> TO.BB COMPLETED BY CENERATOR: <br /> I certify that the Mowing informaUuu iso cxa.and 1 taw road and mtttnatand the requhwaants for partklpudm in the <br /> Sldicycle CtmdilionaDy FYenept Rnudl Quantity Oetx>raRer Wnste Aaeptattce Pxogtnm. I fudhorcurtify!hut I am a Conditionally Exempt <br /> Small Qualnity Gh for as dA£hW by Fodarala d Cel&snia State regulathms,and this qw mtdY of wase toes not emceed dye spocifted <br /> lbnits for me type of waste being dispp(Iga,1f.ytis Nagle ie'Wer found to exceed amall g09ntity Iynits or comtai4materiela not accepted <br /> under this pro&=,l agnea o.completc a i>Rtardoua wash manifest andoomply with other state regulations ae appropriate. <br /> COMPANY NAME: ..My.Mmi Mart .._.. COMPANY REP: Vinay <br /> COMPANY ADDREM'. 17M N..IW6gn Way - EPA Mel CAL 0=90604 <br /> CCN,SFMB,ZIDr Stock ,CA 95205 SIGNATURE. <br /> COMPANYPtIONE: (209) ._341-r.,22fi4 TITLE: ooaaM;�L,.,tr,�. .DATE: . <br /> TO DE COMPLETED BX STERICYCLE CHECK-IN A I'rENDANT <br /> wASTRTW RiPnDN 1 V.ZtM <br /> WAAU SlTATL S/ p (,T)NTAtNP.R wA.m wrgz) Dw C= <br /> Absorbent WJ FuW 9 2 12.60 <br /> Promssing Fee /� <br /> METHOD OF PAYMENT: CASH m CHECK 11 /CHECK NO. TOTAL PgAIDS 22.60. <br /> S'MLCYCI.G CIIECK-IN A=DANTS(MTTALS IA DATE <br /> PSC.}% RRVMPt CHECK-IN lt1;CLIPT <br /> Y <br />