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<br /> CHECK-g'.N RECEIPT AND CERTIFICATION STATEMENT rH,rr iron,.,,.r"me uenrr.,i '
<br /> TO HE COMPLETED BY GENERATOR; mswar w"e a EPAIBxam,M
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<br /> Icmtlty lh.11h.following information 11-1.and II. leadandundmn,Rd the raq.1..—fm pertwpetW in aw N�"IIt�APIa
<br /> Storlcycle Condlliunnlly t.empl9mall Qumlily OenemlorWuk Acaplance Program.IlLrhmcunily lhatlem aCondkinally P,xempt r"'
<br /> Small Quality 0enmtor a deflncd by Pedenl gad CnllfornlaSlateregulation,,and Isla qunllty ouk docs not axccW dw FPmlaW F.rM ?
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<br /> COMPANY NAME: Rancho San Miguel COMPANY REP: Jesus Jurado _
<br /> COMPANYADORE99f 140 S.Almon Way EPA IDII: ------ --- '
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<br /> CITY,STATE,21Pr _ Stockton.CA 95206 g1cNATuae:r ,f,rW
<br /> COMPANY PIIONEt (209) 992,1463 TITLE:(1•On l�ti r DATE: 2-JO
<br /> TO BE COMPLETED BY ST ERICYCLE CHECK-IN ATTENDANT
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<br /> `l METHOD OF PAYMENT: CASH❑ CHECK❑ CHECK NO.4--L+�Pdll e ` asysmmM
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<br /> ". GENERATOR'S INITIAL COPY -.
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<br /> UIM USMSMMANIFESi
<br /> 12 P.r rzx OMB No 039
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<br /> GENERATOR'S ININAL COPY
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