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06 / 03 ! = ON 12 : 19 FAX 0002 / 1102 <br /> �« s� 11855 White Rock Rd . <br /> MSteric Rancho Cordova, CA 95742 {date : 6/ 12/2019 <br /> C1vif161Ct� fy$�il �rt�l6tiit�ti ( 916) 351-0980 <br /> Time : 8 : 00 AM <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 Stericycie Conditionally Exempt <br /> ; mall Quantity Generator Waste Acceptance Program . I further certify that I am a Conditionally Exempt Small Quantity Generator as deflned 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 /> .ompany Name : Richard Sola Company Rep : Richard Sola <br /> .ompany Address :' 10341 Creek Trail Cir . EPA ID # CAC 003 0 6 730 <br /> INN Stockton, CA 95209 Signature ; FIN <br /> phone Number: 209-478-5001 Title : � (}; ,� FNFI Date : (� Z 1 <br /> TO BE COMPLETED BY STERICYCLE CHECK- IN ATTENDANT <br /> ' General Waste Description (Chemical Hez , AH State f1 of Container Total Waste Total Waste Disp <br /> Constituent, Ph, WTC.) Class Waste Code SA Cont. Type/Size (gal / ft) ( pounds ) Meth Cost <br /> _ead Acid Batteries UW S N /C <br /> 311 Filters NR S 1 Drum $ 11 . 00 <br /> aoN Samples 6 , 1 S 1 5 gal 45 lbs $63 . 00 <br /> .atex Paint NR L 1 5 gal 5 gal N/C <br /> mpty Drums NR S 5 50 gal $ 55 . 00 <br /> FIN <br /> IF <br /> FIN <br /> IF <br /> IN IF IIFNN <br /> ) rocessing Fee $ 20 . 00 <br /> Method of Pymnt: Cash Check# j Inv Total Paid : $ 149 .00 <br /> itericycle Check-In Attendants Initials : Date : —� � � <br />