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�� • 11855 White Bock Rd, <br /> Ster"cycleanchoRCordova, CA 95742 Date : 5/ 15/2019 <br /> (916) 351-0980 <br /> Time , 9 :45 AM <br /> CONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR WASTE CHECK414 AND CERTIFICATION <br /> RECEIPT AND CERTIFICATION STATEMENT <br /> To be completed by the generator : <br /> I certify that the following information is correct, and 1 have read and understand the requirements for participation in the Stericycle Conditionally Exempt <br /> t <br /> f <br /> small Quantity Generator Waste Acceptance Program. I further certify that I am a Conditionally Exempt Small Quantity Generator as defined by Federal and i <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 other E <br /> state regulations as appropriate. , <br /> Company Name, Food 4 Less Paq Inc , Company Rep: Eloy Galvan <br /> Company Address , 17935 Murphy Pkwy , EPA ID # N/A <br /> Lathrop, CA 95330 Signatur <br /> Phone Number: 209-992-7990 Title � jr =1 qCl> Date: <br /> TO BE COMPLETED BY STERICYCLE CHECK- IN ATTENDMT <br /> General Waste Description (Chemical Haz. AH State SA Total of Container Total Waste Tatal Waste Dtsp <br /> Constituent, Ph WTG.) Class Waste . Code Cont, Type/Size (gat / ft) (pounds) Meth C6St <br /> 4 ' Fluorescent Bulbs UW S 451Y 4 ' tubes (1400 <br /> I <br /> l <br /> F <br /> 1 <br /> t <br /> t <br /> Processing Fee $2.0 . 00 <br /> Method of Pyrrint : Cash Check# Ae7 Inv Total Paid : <br /> $ 9A9 <br /> Sterlcycle Check-In Attendants Initials: Date. <br /> I <br />