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Rancho Cordnva; CA 957.42 <br /> Date : iiJ6f2019 <br /> L, V (916) 351w0§80 <br /> Time : 9: 15 A <br /> CONDITIONALLY EXEMPT SMALL QUANTITY GENERATORWASTE CHECK4N AND CERTIFICATION <br /> RECEIPT AND CERTIFICATION STATEMENT <br /> To be eompi.eted by the generator , <br /> I certify that the following information is correct; and I .have read and understand the requiremerrts for -participation in the Stericycie Conditionally Exempt <br /> mail Quantity Generator waste Acceptance Program. I further.certifjr that I am a Conditionally Exempt Small Quantity Generator as defined by Federal and <br /> .alifornia State Regulations, and this quantity of waste does not exceed the specified limits for the type of waste being disposed,.. If this waste its later found <br /> to exceed small quantity. limits or contain material's not accepted under thtsprogram lagree to complete a hazardous waste manifest and comply with <br /> otherstate regulations.as appropriate. <br /> :ornpany Name: JKCTruckirig Company Rep : Ma(isa Rose <br /> :ompany Ad-dress: 3.400 Newton Road €PA .ID # <br /> CAL 000 405 278 <br /> Stockton CA 95205 Signature : ®� `i <br /> 'hone Number: 209489 2457 <br /> Title,: ki� Date: 6 B <br /> TO BE COMPLETED BY STERICYCLE CHECK-IN ATTENDANT <br /> General waste Description (chemical tiaz. AH state # of container Total Waste Total waste Disp <br /> 'Constituent, ph,. WTC:} Class wane - {ode SfL Cont. Typelsize (gal Pft). (pounds) Meth Cost <br /> mpty Drum (LC. Oil) NR S 3 55 gal S11:Ofl <br /> -ocessing Fee <br /> 520:00 <br /> ',ethod of Pymnt: Cash �( Check# In Total Paid: 31,®p <br /> ericycle Check-in Attendants initials. Date: �� f <br />