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0 • �+ ,tTr�y 11855 White Rock Rd. <br /> Ivv«,fi� Stern L Rancho Cordova,CA 95742. Date: 11/20/20119 <br /> (916)351-0980 <br /> �rxyttcJn'r`�n2a;�tri;r, � <br /> Time: 9:30 AM <br /> CONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR WASTE CHECK-IN AND CERTIFICATION <br /> RECEIPT AND CERTIFICATION STATEMENT <br /> To be completed by the generator: 71 <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 Conditionaliv Exempt Small auantity 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 smail 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: Trans American Inc. Company Rep: Christina Clark <br /> Company Address: 1838 Vicki Lane EPA ID# CAL 0t'0 450 448 <br /> Stockton,CA 95205 Signature: ------- <br /> Phone Number: 219-898-1932 Title: Date: <br /> TO BE COMPLETED BY STERICYCLE CHECK-IN ATTENDA <br /> General Waste Description(Chemical Haz. AH State S/L 11 of Container Total waste Total Waste Dip Cost <br /> Constituent,Ph,WTC.) Class Waste Code Cont. Type/sire (gal/ft) (pounds) Meth <br /> Empty Drum (L.C,Oil) NR S 2 55 gal —80 lbs $22.00 <br /> Motor Oil NR L 1 5 gal 3 gal N/C <br /> Absorbent NR S 1 5 gal 20 lbs $28.00 <br /> Fire Extinguishers 2.2 S 4 15 lbs $58.00 <br /> Empty Container NR S 1 5 gal 2 lbs $2.80 <br /> FProcessingFee $20.00 <br /> Method of Pymnt: Cash Check# Inv I Total Paid: $130.80 <br /> Stericycie Check-in Attendants Initials: Date' <br /> e <br />