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21855 White Rock Rd. <br /> Stericycle' <br /> Rancho Cordova, CA 95742 Date: 12/18/2019 <br /> i (916) 351-0980 <br /> Time: 10:00 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 5tericycie Conditionally Exempt <br /> Small Quantity Generator Waste Acceptance Program.I further certify that i am a Conditionally Exempt Small Quantity Generator as defined by I=ederal 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: Sierra Pacific Stockton Cold Storage Company Rep: Thomas Holdener <br /> Company Address: 1320 W. Weber Street EPA ID# CAL 000 189$ 1 <br /> Stockton, CA 95206 Signature: <br /> Phone Number: 209-423-8094 Title: /Yta i)TA: Date: 17, —18—1 q <br /> TO BE COMPLETED BY STERICYCLE CHECK-IN ATTENDANT <br /> General Waste Description(Chemical Haz, AH State SQL #of Container Total Waste Total Waste Disp Cost <br /> Constituent Ph,WTC.) Class Waste Code Cont. Type/sire fgal/ft) {pounds) Meth <br /> Metal Halide Lamps UW S 1 50 gal 45 lbs $135.00 <br /> 4' Fluorescent Bulbs UW S 12 Boxed 48' $7.20 <br /> l <br /> Processing Fee 1 $20,00 <br /> Method of Pyrnnt: Cash Check# Inv ITotal Paid: $162.20 <br /> Stericycle Check-in Attendants Initials: Date: 1p2-:- <br /> � <br /> Ire <br />