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<br /> LI•Steric �Arr
<br /> Y/���ra�G` 11855 White Rock Rtl. Sterscycl0 „g r n� r'
<br /> Rancho Cordova,CA95742 p��s n C t Ounivn�Gn nsmv r
<br /> (916)351-0980 OdYe: 2/21/2020 `� fvid)l do'No Ta"
<br /> Time: 8:15 AM CONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR WASTE
<br /> CONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR WASTE CHECK-IN AND CERTIFICATION CHECK-IN RECEIPT AND CERTIFICATION STATEMENT
<br /> RECEIPT AND CERTIFICATION STATEMENT -- ---- TO B1:COMPLETED 8Y GENERATOR:
<br /> Tobe completed by the generator
<br /> emYth:t the 1°.loxing in:a.maaoa Boon L certify tint the following information u conec4 xad L have read and understand We req°iremeott for Pvticipatiaa N the
<br /> Small quanf eat anal nave rcadand undersknd mere ,ellycle ConditioaallY ExemPtSmall Quamiry Geacmtor Wazte Acupunu Program.IfnMerurtiCy War lamaCoMitiomlly Ezraapl
<br /> MOer...mrw.neAeaounrepdgr m.I runnarcenly tw,lamaeonaltknlany Exempts nll,wnon k,nasa<dryck cprwmomlw Eaempr Quamiry Gcoans azdef ce by Fcdeml and Calitbmia State reguktioau,and this giuntiry of wask don no[aaud Wes fm
<br /> Glaar"«Sante gagula,gns,andtM1B quantay prwane does not exceed tM1e sveri0etl limbs for thea P<p
<br /> k et< dsmail qua nntylimttsorepnkln materaBne[accevretl untl¢rthlspragram la m,QYamhy Generakr asdNrtd WiMenlaM 'iaa tfhor,the type of avas[e being disposed If Ibis wazte i¢Iatu foupdmexeeed small Qaamify limits or cOnmie rnaluie(s iplaucpad
<br /> Ypaolwa,abaingdhposed.lrah;s wa,abbw Lwnd ler rs program Iagree to aomplctea LaTardous waste masaiF rand wmpty wiW oWerstffie mguladoos azappropriatc,
<br /> oNerskte regulaalon greet°complete aaaxardous waste manifertand mmpar,ran
<br /> Company Nam¢: s sappropn.te.
<br /> Ranc_
<br /> Company Address: h
<br /> - a__Mlguel Company Rep: (�I
<br /> 14095.Airport Way Jesus JuradO a1PANY rvAME: 12�'D -_ COMPANYREP: JC;
<br /> Stockton,CA 95206 EPA ID# CAL000284823 — MP' V"DRE55: (�[-(rYJ yg yg 23
<br /> phnn _ _ /61-_�_�j EPAIOa:
<br /> a c- 209 992 1463 $Bnatu e ( Y,"PATE,ze'; an,t,_P� ( SIGNATURE:
<br /> TO BF[Of4PLETED BYSTERICYCLE Title:campl;mx Nan or Date:xrzs 0 '°m PH'Orve: -'Y /2
<br /> C'jD�I ,Q TITLE: DATE
<br /> ee"ami wane oes<.;Ion CM1emrx —ATTENDANT _
<br /> eonnhae",,vn wrcd 1 Nex ate Canr i TO BE COMPLETED BY STERICYCLE CHECK-IN ATTENDANT
<br /> ansa I w,tt cone vE nor /or. Toulw,na soul waau
<br /> 4'Fluorescent Bulbs Cons. rroeA;<, W;rhl AVERAcwasrs oQCamDo
<br /> Oyy $ $0 (p°unyl COSI t•ECALCONSTITIEaaT a'4 E(C. CVS,S STAIE S/ AOF _NPADELTf WASTE R'1LIa7 IaLAS ODS(
<br /> Boxed 200' �� WASTE 000e L &m, TYP&5I. _uNr gviN
<br /> $30.oc QI 250 325
<br /> 1
<br /> I!
<br /> $20.00
<br /> L Inv Total Paid: . OF PAYMENT. CASH CHECK CCHECK NO.
<br /> '
<br /> Date: CHECK-Di ATTENDANTS w=iTnL:.
<br /> 1 I(�
<br /> CE_SQG TR KING SHEET NO: � •' 1855 MO CON OVA.CAD
<br /> I �� 8terkyCle'RANCHO COItOOVA,CA 95742 D f E Febiyary 3,2016
<br /> -- (916)3510980 n
<br /> Informed.
<br /> Busmen"InCarmaaon nm
<br /> u Penl<IpetW
<br /> App,.d„, Tarr. EPA ID Namb<a,ifany CONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR WASTE
<br /> Phmu
<br /> FAN EuzMAi R<g,smnon n,;f any CHECK-IN RECEIPT AND CERTIFICATION STATEMENT
<br /> Bas�<r.N,m, E""Add—, TO BE COMPLETED BY GENERATOR:
<br /> Ma3ing Address T)P Of Basin<ss t certify Waz the following inform,vtion is coned,and 1 hnvp reed and undvemnd Wa raquvemrnu[or pldtidipmion W We
<br /> Skrirycuenaonditionally Exempt Smail Qamtlty Generator Wasla Auepknu Progrem.I fnhcrconify that 1 am a Conditionally Exempt
<br /> Suui.iddress ifd:((eren,from maiWgadd,eu 3and,Q ryMGenerator.defined by Federal and Ceiifomie Sale regulations,ana Wie quantity of wask does out exceed We specified
<br /> Iuvik for We type ofwane being diapored.If Wia week is kter found to exceed smell quantity limits or contain makrub sat ec«pkd
<br /> Wane Deadpnaa ,der Wie program,I agree to aropi<a a ham Ow,este manifas,end comply wiW otAv rtate regulations az eppropriek.
<br /> Type of U'as,c Qoanriry Pare Total � '
<br /> COMPANYNAME; RRnch.San MI0001 COMPANYREP;
<br /> COMPANYADDRE99: 1409 S.All Ori Wa Jeell9 Jurado
<br /> P Y EPAIDa: CAL 000284823
<br /> CITY,ETATE,ZIP: Stockton,GA95206
<br /> COMPANYPHONE: SIGNATURE:
<br /> (2091 _992-7463TITLE:r O�VG DAiE: 'Z_a= 5(/
<br /> . te_
<br /> TO BE COMPLETED BY STERICYCLE CHECK-IN ATTENDANT
<br /> l�I rOENegAL WAST¢nBSCNIpriON NA2 ss
<br /> STATE 5CODEl r OF CONrAAME, WASTE
<br /> I CLCM1OCAt.
<br /> CON To
<br /> CDNT W") DISP. COST
<br /> Lound Deter ant NE A1E1t'
<br /> PAYhfENT IS DUE ON DISPOSAL Wane cone BBS 1 yp 55 a A 100
<br /> Bleach 5 1 130-
<br /> Pa)'men,by check or evnbLshed arcaun,oNy NO f H WI B AC FPTF Lobo, 10 140-
<br /> M-"`E`
<br /> 40-payablem"Sawa,Villcy Solid Wua Au,homy" Ma,eaal
<br /> TOTAL
<br /> Su,e and FOded huudoa,waste hors kni,We use of CESQG wartOetcoBecdon
<br /> than 100 kdograma(about 27 p,ognmr,o bouncases Wat gencnmlcas Processin Fee
<br /> ha:a,d°aa—Na" Ballon,or 220Ibr.)of hazudour wnsl<pe,monW a,d les,Wan 1 kilogram of"eaNvndy 2_
<br /> per monW.
<br /> hfy aip�u,ure bdow"ra6cr that Ircpaacnr the bum—hued above and,Lot thin bualnaa
<br /> haaudooa wa tc per month and kr,Wan 1 keg of"exuvncly haaa,doaso Pet_aWgenetatu 1—d"'100 kg of.
<br /> My signature below ilro by the s,baa rho" I am onaranang m sh<CESQG Call don pg,_wc,<gcneuaod vi,Ain
<br /> the SVSWA remce un by du buaneu kcal above and Wa,I have Irmafcc,ed aheae wastes to rhe SVS WA PHHWCF foe
<br /> proper mwgvnrn,and/a,dupoail.
<br /> S,gssama --
<br /> Name/Tide/Darc
<br /> F METHOD OF PAYMENT: CASH❑ CHECK(3 CHECKNO.
<br /> _V
<br /> 39IMRAL$ L
<br /> TOTALPAID$ 29000 ch.licrna aY Su((I,atiila Check 7!/Amosml ENDAN ' �
<br /> To Invoice -C.pEpEp pNtD Lmwem ySL7 DATE 2 t,
<br /> A •. CHECK-M RECEIPT I
<br /> ram..-.
<br />
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