Laserfiche WebLink
Rancho Cordova, CA 95742 Date: "16/7-019 <br /> (916) 351-0980 <br /> 7 rn e: 9:15 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 /> [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 ConditionaFy Exempt Small Quantity Generator as defined by Federal and <br /> California State Regulations,and this quantity of waste does not exceed the specified firnits for the type of waste being disposed.If this waste is lalerfound <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: JKC Trucking Company Rep: Malisa Rose <br /> Company Address: 3400 Newton Road EPA ID # CAL 000 405 278 <br /> Stockton, CA 95-205 Signature: <br /> Phone Number: 2.09-489-2457 Title: Date: <br /> TO BE COMPLETED BY STERICYCLE CHECK-#N ATTENDANT <br /> General Waste Description(Chemical Haz. AK State SIL <br /> of Container Total Waste Tota I Waste Disp Cost <br /> Constituent,Ph,WTWaste) Class Waste Code Cont Type/Size (gal ft) (pounds) meth <br /> Empty Drum (L.C. Oil) NR S 1 55 gal $11.00 <br /> Drocessing Fee $20.00 <br /> Method of Pyrnnt: Cash Check# Inv Total Paid: $31.00 <br /> >tericyde Check7ln Attendants Initials-, Date: <br />