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StericycVRan"855White Rock Rd. <br /> cho Cordova, CA 95742 Date: 7/3/2019 . <br /> (916) 351-0980 <br /> Time: 8:45 <br /> AM <br /> CONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR WASTE CHECK-IN <br /> 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 Sterfcycle 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: Artistic Ornamental Iron Work <br /> Company Rep: Ernesto Gonzalez <br /> Company Address: 2228 N. Wilson Way EPA IU # CAL OOQ 345 866 <br /> Stockton, CA 95205 Signature: y <br /> Phone Number: 209-598-7700 <br /> Title: vi.�/L, of�K-- Date: � s <br /> TO BE COMPLETED BY STERICYCLE CHECK-IN ATTENDANT <br /> General Waste Description(Chemical Haz, AH State S/l. #i of Container Tote Waste Total Waste <br /> Constituent, Ph,WTC.) Class Waste Code �IsP <br /> Cont. Type/Size (gal/ft) (pounds) Meth COSI <br /> Metal Wash Waste 3/6.1 L 1 1 gal 1 gal <br /> $8.25 <br /> rocessing Fee <br /> 4ethod of Pymnt: Cash $20.00 <br /> Check## 2 Inv Total Paid: <br /> tericycle Check-In Attendants Initials: $28.25 <br /> Date: <br />