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o �, i 11855 White Rock Road <br /> 000 �'✓ �i U'UyC tri Rancho Cordova,CA 95742 Date: <br /> (916)351.0980 <br /> Time: <br /> CONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR WASTE CHECK-IN AND CERTIFICATION <br /> RECEIPT AND CERTIFICATION STATEMENT <br /> To be completed by the generator: <br /> I certify that the following information is correct,and I have read and understand the requirements for participation in the Stericycle Conditionally Exempt <br /> Small Quantity Generator Waste Acceptance Program.I further certify that I am a Conditionally Exempt Small Quantity Generator as defined by Federal and <br /> California State Regulations,and this quantity of waste does not exceed the specified limits for the type of waste being disposed.If this waste is later found <br /> to exceed small quantity limits or contain materials not accepted under this program I agree to complete a hazardous waste manifest and comply with <br /> other state regulations as appropriate. <br /> Company Name: ON_- C_.' i--w i--I ,I L Company Rep: <br /> Company Address: I j c ), i1 L.L:y <br /> C- 0 "�' S Signature: <br /> Phone Number: L t Title: Date: c <br /> t =I (L ):2 <br /> TO BE COMPLETED BY STERICYCLE CHECK-IN ATTENDANT <br /> General Waste Description(Chemical Haz. AH State SQL 0 of Container Total Waste Total Waste Disp <br /> Constituent,Ph,WTC..) Class Waste Code Cont. Type/Srze (gal/ft) (pounds) Me:h Cost <br /> Ic— <br /> Processing Fee )?C <br /> et`,od of Pymnt: Cash Check# Inv Total Paid: <br /> . .._ e C'.eek-I-i At`endants initials: i Date: <br /> Ir <br /> �T41 `i�t"• "yD;ztil:L'vGIN <br />