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a • 11855 WHI FL ROCK ROAD Imte,.I i.vent March 2, 2016 <br /> Stitrkyeltiv RANCHO QORDOYA,CA 95742 '1 time: 12:00pm <br /> (916)351-0990 iePonnad: <br /> Thins Participsted: <br /> CONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR WASTE <br /> CW,,CK-IN RECEIPT AND CERTIFICATION STATEMENT <br /> TO BE COMPLETED BY GENERATOR: <br /> 1 certify that the following information is comet,and i have read and understand the requirements for participation in the <br /> Stericycle Conditionally Exempt Sinai Quantity Generator Waste Acceptance Program, t further certify that I am a Conditionally Fxe rpt <br /> Small Quantity Generator se defined by Federal and California State regulations,and this quantity of waste dows not exceed the spec ted <br /> limits for the type of waste being disposed. If this waste is later found to exceed small quanfin limits nr containmaterials not accarted <br /> under this program, I agree to complete a hazardous waste manifest and comps- - i.'', iher ,ms as appr,priate.. <br /> COMPANY NAME: George's Mini Mart COMPANY KFP; Bikram Sodhi <br /> COMPANY ADDRESS: 18662 N. Hwy 88 &PAID#* CAL 000287525 <br /> CITY,STATE,ZIP: Lockeford, CA 95237 SIGNATURE: <br /> COMPANY PHONE: (209 ) 814-0300 TITLE: DATE: <br /> TO BF. COMPLETED BY STERICYCLE C1119(.7K-IN ATTFNDANI' <br /> 4NURAI WASTE DM-XIEMON `HAZARD AH S1A7E Sp r 0001 OcNTAWFA WASTE wit1,81 - I <br /> (l i7FSfic AI ((Ns 1117 IF.N'I'.Ph-FTC 1 CLASS wAs'B CODE L I CONT '1"(WR17T I AM01'NY <br /> Absorbent wl Diesel 9 2 5gal 15 19 50� <br /> I <br /> �yyy I I <br /> (Processing Fee 0- <br /> EG WEE <br /> ! MAR <br /> {LF.,XiRONMENT,1 L <br /> i I I CA�TJ 1CD1pT�AC�IT ' <br /> I N i <br /> I � i <br /> , <br /> METHOD OF PAYMENT: CASH O CHECK ❑ C�HKCKNO. <br /> I <br /> STERICYCLECHRCK-IN ATTENDANTS INITIALS V�" IL UA7l� ,�I(J�J I kj <br /> PNC-"7 "VN135 ('}110CK-rN REC IPT <br />