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e � <br /> Stericycle, Rancho Cordova,CA 95742 Date: 12/11/2019 <br /> e <br /> (916)351-0980 <br /> Time: 8:45 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 I 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 1 agree to complete a hazardous waste manifest and comply with <br /> other state regulations as appropriate. <br /> Company Name: Lathrop Woodworks Company Rep: Sonya Looney <br /> Company Address: 16175 McKinley Ave. EPA ID# CAL qO 038179 <br /> ,� .. Lathrop, CA 95330 Signature: ' <br /> PhWe Number: 209-858-4173 Title: Vj;C Date: <br /> TO BE COMPLETED BY STERICYCLE CHECK-IN ATTENDANT <br /> General Waste Description(Chemical Haz. AH State SQL #of container TateI Waste Total Waste Disp Cost <br /> Constituent,Ph,WTC.) Class Waste Code Cont. Type/Size (gal/ft) (pounds) Meth <br /> Cont. Motor Oil NR L 5 5 gal 25 gal $87.50 <br /> Processing Fee $20.00 <br /> Method of Pyriint: Cash Check# Inv Total Paid: $107.50 <br /> Stericycle Check-In Attendants Initials: Date: 1,4114 4 '� • „� <br /> k)111 pal Xt--e t- r5 ry- L—aLf\_ <br /> I <br />