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• 1 11855 White Rock Rd. <br /> 1 <br /> xv,,"mcyde Rancho Cordova,CA 957"42 I�atE', �f 5 202.0 <br /> r <br /> (916)351-0980 <br /> :r:V`,fSlf<'�►i•4�at� t��y3Ci+�"�=i <br /> Time: 8:00 AM <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 5tericycle Conditionally Exempt <br /> smali.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 complywith <br /> other state regulations as appropriate, <br /> Company Name: Suvik Farms Company Rep: Chris Bettencart <br /> Company Address, 1.1959 French Camp Road EPA ID 9 CAL 000 445 9.08 <br /> Manteca, CA 96336 Signature: _ <br /> Phone Number: 209-985-8392 Title: Date: —TO BE COMPLETED BY ST>ERICYCLE CHECK-IN ATTENDANT <br /> General Waste Description(Chemical H.az. AH State S/t #of Container Tota!Waste Total Waste wisp <br /> Constituent,Ph,WTC.) Class Waste Code Cant. Type/Size (gal/ft) (pounds) Meth COSI <br /> Non-PCB Ballast NR 5 17 lbs $13.60 <br /> �l <br /> I Mcessing Fee $20.00 <br /> Method of Pymnt: Cash Check# C C- on i 1 Total Paid: .2 j5 io <br /> Stericycle Check-In Attendants Initials: Date: aC) <br /> V f0 64-W 1©Z, 3G 1 <br />