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CONDITIONALLY EKGs KPT SMALL QUANTfI' Y GENERATOR WASTE <br /> CHECK- IN RECEIPT AND CERTIFICATION STkTEMENT <br /> r TO BZ COMPLETED BY GENERATOR.: ' <br /> it <br /> � cki y t tie. italLa wrong ir[fnr,:oatiox Is corrubst, mad I ftave :rmad =dAjnde:mmad lha regusremr-flts fDrpa�cipaCSon u¢ the <br /> �c cy ar tirn 1 � r�i�t � lal !C r r i h :C vera � r Ja t� A ce{ Cafle ��es�sr�m. Acr eFyjtha$ tam a CjWA& uantaRy Exempt <br /> ad Quantity Gee. erator as defuied by Federal and Califoraia State reguladoas, aed this quantity of haste does not exceed the specified <br /> 'nitstfor -�&e lype o svaswb d+isPoseet H&L waste cxcj=d smaU quangrWNzatits or contain matmials mot ftcCepted <br /> :er this program, I agree to complete a hazardous waste manifest and comply with other state regulations as appropceate. <br /> ELI A <br /> vtrANY ADDRESs : : € `a EFA IEfg: <br /> Wj <br /> Y, STkTTE, ZXr & &&GEF ZE: <br /> , ' <br /> a. <br /> PAIrIYPErON'E: Cz } qq 9L 1gC10 TITLE: � n DATL: <br /> mill <br /> rAa, <br /> TO BE CaWLETED BY• ISTERICYCLE CHECI&IN ATT � ANT <br /> WMA-Ltf 5EF! cR1PTTC 1W*RD - AW sties . . *0 <br /> ky <br /> is <br /> 1I ' Qq <br /> 91it <br /> d <br /> OPT IF P <br /> it <br /> 44 <br /> It <br /> too <br /> IRS <br /> vp <br /> I EA <br /> P it <br /> It <br /> IN IN IN I I <br /> C. <br /> i . . <br /> e <br /> E10D OF P.AYNEEN C: CASER Q CPM" CK Q CRECY t1C?. . • . TOTAI PAID S <br /> L 0 �,/ T l �'_ �J DATE <br /> ,R5RX TN AR lit <br /> . t <br />