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too118 White Rock Rd. <br /> bterICYC16 Ranch2 Cordlova, CA 95742 <br /> Dade. 5/15/219 <br /> g (916) 351-0980 <br /> Time: q: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 Stericycle Conditionally Exempt <br /> Small Quantity Generator waste Acceptance Program.l further certify that l 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 Name: Hernandez Auto Body& Paint Company Re <br /> p y p: Raul Hernandez <br /> Company Address: 840 E.Jefferson St, EFA ID# <br /> AL,000 361175 <br /> Stockton, CA 95206 Signature: i, <br /> Phone Number: 209-981-6956 Title: � i✓�.J . � Date: <br /> TO BE COMPLETED BY STERICYCLE CHECK-IN ATTENDANT <br /> General waste Description(Chemical Haz. AH State #of Container Total waste Total waste <br /> Constituent,Ph,wTC.) Class waste Code S/L o;sp <br /> (pounds} vieCont. Type/Size (gal ft) ch Cost <br /> i Laquer Thinner(empty) 3 L 15 5 gal <br /> $Mb <br /> processing Fee <br /> $20.00 <br /> Method of Pymnt: Cash Check# Inv $ <br /> Total Raid: <br /> teri.;. e Check-in Attendants Initials: �sh <br /> —; <br /> - <br /> CREDIT CARD ENDING IN - <br /> J <br /> 3 <br />