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11855 White Rock Rd. <br /> is'.1s Stericyde� Rancho Cordova, CA 95742 Cate: 12/11/2019 <br /> (916) 351-0980 <br /> Time: 8:30 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 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 Dame: Amberland Composites, LLC Company Rep: Seng Kingkhilysack <br /> Company Address: 3632 Duck Creek Drive STE F EPA ID # CAL 000 309 586 <br /> Stockton, CA 95215 Signature: <br /> Phone Number: 209-603-1477 Title: Date: <br /> TO BE COMPLETED BY STERICYCLE CHECK-IN ATTENDANT <br /> General Waste Description(Chemical Haz. AH State #of Container Total Waste Total Waste Disp <br /> Constituent,Ph,WTC.) Class Waste Code SIE Cont. Type/size (gaI/ft) (pounds) Meth COSI <br /> Paint 3 L 1 1 gal 1 gal $3.50 <br /> Acry Shield Paint 3 L 1 1 gal 1 gal $3.50 <br /> Paint/Penetrol 3 L 1 1 gal 1 gal $3.50 <br /> Resin 6.1 L 1 5 gal 5 gal $41.25 <br /> Sanding Primer 3 L 1 5 gal 5 gal $15.00 <br /> GelCoat 3 L 1 5 gal 5 gal $15.00 <br /> Empty Container w/ residue NR S 1 5 gal 2 lbs $2.80 <br /> Processing Fee $20.00 <br /> Method of Pymnt: Cash Check# Inv Total Paid: $104.55 <br /> Stericycle Check-In Attendants Initials; Date: <br />