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nericycle <br />r <br />Frwitow,n it'all t y3Ci+ =i <br />11855 White Rock Rd. <br />Rancho Cordova, CA 95742 <br />(916) 351-0980 <br />Date: <br />Time: <br />CONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR WASTE CHEC <br />RECEIPT'AND CERTIFICATION STATEMENT <br />E To be completed by the generator: <br />x/5/202.0 <br />8:00 AM <br />WN AND CERTIFICATION <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 />SmaJI.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 <br />Company Rep: Chris Bettencart <br />Company Address, 1.1959 French Camp Road EPA ID 9 CAL 000 445 908 <br />Manteca, CA 96336 Signature: <br />. <br />Phone Number: 209-985-8392 Title: n;itp- _ � _ n ^ <br />TO BE COMPLETED BY STERICYCLE CHECK-IN ATTENDANT <br />General Waste Description (Chemical <br />Constituent, Ph, WTC.) <br />H.az. <br />Class <br />AH <br />Waste <br />State <br />Code <br />S/t <br /># of <br />Cant. <br />Container <br />Type/Size <br />Tota! Waste <br />(gal / ft) <br />Total Waste <br />(pounds) <br />wisp <br />Meth <br />COSI <br />Non -PCB Ballast <br />NR <br />5 <br />17 lbs <br />$13.60 <br />-I Ltas <br />rg� ,5 <br />'recessing Fee <br />$20.00 <br />ivie_noa OT vymnr: c:asn Check# C.c Total Paid: reg <br />- <br />Sterieycle Check -In Attendants Initials: bate: -31,5,1,'ao <br />ViQ 64-,W 1 ©Z, 3G 1 <br />