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®®� 11855 White Rock Road <br /> teP"IcyCle• Date: <br /> e Rancho Cordova,CA 95742 <br /> (916)351-0980 �t7 � ' <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 /> Jother state regulations as appropriate. <br /> Company Name: w �( A L [. -w- l j L Company Rep: <br /> Company Address: I I c S iA LL`h_t"'i`7 Q� EPA ID # G r Uc�J3t•l Gc y. <br /> a Signature: <br /> Phone Number: L L J Ll Title: Date: 0 C. J C. <br /> TO BE COMPLETED BY STERICYCLE CHECK-IN ATTENDANT <br /> General Waste Description(Chemical Haz. AH State S/E q of Container Total waste Total Waste Disp <br /> Constituent,Ph,WTC.) Class waste Code Cont. Type/Size (gal/ft) (pounds) Meth Cost <br /> 3� yL, <br /> Processing Fee <br /> Method of Pymnt: Cash Check# Inv Total Paid: <br /> T-713 <br /> -•tc e Check-In Attendants in;tials: l( Date: <br /> EEiG*� hRD CIN <br />