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11855 White Rock Rd . <br /> I�. 4F a 3 Rancho Cordova , 6/25/2020 <br /> CA 95742 Date : <br /> (916) 351-0980 <br /> F Time : 8 : 15 AM <br /> r <br /> { CONDITIONALLY EXEMPT SMALL . QUANTITY GENERATOR WASTE CHECK- IN AND CERTIFICATION <br /> RECEIPT AND CERTIFICATION STATEMENT <br /> s <br /> f 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 . I further certify that I am a Conditionally Exempt Small Quantity Generator as defined by Federal and <br /> I 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 other <br /> state regulations as appropriate. <br /> Company Name : Rancho San Miguel Company Rep : Jesus Jurado <br /> Company Address : 1409 S . Airport Way L EPA ID # CAL 000 284 823 <br /> Stockton , CA 95206 Signature : <br /> Phone Numbers 209-9924463 Title : Compliance IanagerDate : 6/25/2020 <br /> TO BE COMPLETED BY STERICYCLE CHECK- IN ATTENDANT <br /> General Waste Description (Chemical Haz. AH State # of Container Total Waste Total Waste Disp <br /> Constituent, Ph, WTC. ) Class Waste Code S�� Cont. Type/Size (gal / ft) ( pounds) Meth COSI <br /> Moo <br /> 4' Fluorescent Bulbs UW S 40 Bulbs 160 ' $ 24 . 00 <br /> Processing Fee $ 20. 00 <br /> Method of Pymnt : Cash Check# Inv . Oh - Total Paid : $44. 00 <br /> Stericycle Check- In Attendants Initials :) - pate : <br /> o �� <br />