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# �► 11855 White Rock Rd . <br /> # # <br /> Stericycle Rancho Cordova, CA 95742 Date : 2/27/2019 <br /> (916) 351-0980 <br /> 4— t�i���q 'I�f��t�el�i 3�1•�ffry��J <br /> Time : 8 : 15 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 Stericycle 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 : Lustre Cal Company Rep : Rob Krager <br /> Company Address : 715 5 Guild Ave . EPA ID # CAR 000 154 922 <br /> Lodi , CA 95240 Signature : <br /> Phone Number : 209-370- 1600 Title : Date . <br /> 1111 <br /> TO BE COMPLETED BY STER { CYCLE CHECK-IN ATTENDANT <br /> General Waste Description (Chemical Haz. AH State S/t 11o, Container Total Waste Total Waste Disp Cost <br /> Constituent, Ph, WTC . ) Class Waste Code Cont. Type/size (gal / ft) ( pounds ) Meth <br /> Fluorescent Tubes UW S 95 4 ' 380 ' $ 57 . 00 <br /> CFL' s UW S 3 $ 3 . 75 <br /> Oil Filters UW S 25 $0 . 00 <br /> Aerosols 2 . 1 S 22 15 $ 21 . 00 <br /> Ink 6 . 1 L 2 2 $ 2 . 80 <br /> Lead Acid Batt . (taped ) UW S 2 2 $ 0 . 00 <br /> Way Oil 3 L 3 5 gal 15 $ 52 . 50 <br /> Klean Strip Thinner 3 L 1 1 qt 0 . 25 $0 . 87 <br /> Miscible Cleaner G42 3 L 1 . 5 qt 0 . 12 $ 0 .42 <br /> Glaz a Way 3 L 1 1 qt 0 . 25 $0 . 87 <br /> Cleaner 909 D2 9 L 1 2 qt 0 . 5 $ 1 . 75 <br /> Processing Fee $ 20 . 00 <br /> Method of Pymnt . Cash Check# Inv Total Paid : $ 160 . 96 <br /> Stericycle Check- In Attendants Initials.. Date : <br />