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So 11855 White Rack Rd. <br /> Ste le Rancho Cardona, CA 95742ricyc Date . <br /> i (916) 351-0980 <br /> �C+riS <br /> Time . <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 . I 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 I agree to complete a hazardous waste manifest and comply with <br /> other state regulations as appropriate. <br /> Company Name: Food4l ess Pawnc, Company Rep : Eloy Galvan <br /> Company Address: 17935 Murphy Parkway EPA ID # N/A <br /> Lathrop, CA 95330 Signatur <br /> Phone Number: 209-992-7990 Title : dLkr,1 ,�f(` pate : <br /> TO BE COMPLETED BY STERICYCLE CHECK-IN ATTENDA T <br /> General Waste Description (Chemical Haa. AH State SIL # of Container Total Waste Total Waste oisp <br /> Constituent, Ph, WTC.) Class Waste Code Cont. Type/Size ipl / ftlCost <br /> (pounds) Meth <br /> Fluorescent Tubes UW S 1619 4' 6476 ' $971 .40 <br /> Processing Fee $ 20.00 <br /> fiethod of Pymnt: Cash Check# �' �" Inv $991.40 <br /> Total Paid : <br /> Stericycle Check-in Attendants Initials: Date: - f— _ <br />